The patient is an 85-year-old female with heart failure, significant aortic stenosis, low EF, ostial left main (LM) disease and a right coronary artery (RCA) lesion. The case entails peripheral Shockwave for femoral access and Protected PCI. In addition to highlighting hostile peripheral anatomy, the case illustrates how to manage difficult wiring and how to manage a dissection. Hursh Naik, MD, and Riyaz Sumar, MD, offer this live case from St. Joseph’s Hospital and Medical Center in Phoenix, Arizona. Seth Bilazarian, MD, and panelists Aditya Bharadwaj, MD, and Mark Bieniarz, MD, provide commentary on the case and emphasize the importance of having a plan in place before starting the procedure and then being amenable to changing that plan as the case evolves.