Thom Dahle, MD, and Stephen Kidd, MD, from St Cloud Hospital in Saint Cloud, Minnesota, share this live, complex, high-risk PCI case with Seth Bilazarian, MD, and panelists Kate Kearney, MD, and Ankitkumar Patel, MD. The patient is an 85-year-old male who had been turned down for surgery due to age, comorbidities and a heavily calcified aorta. He had normal ejection fraction (EF), but extreme coronary complexity as well as severe peripheral artery disease precluding femoral access for Impella. The team performs Protected PCI with percutaneous axillary insertion of Impella. They use rotational atherectomy (RA) and Shockwave intravascular lithotripsy (IVL) in heavily calcified lesions on both the left and right sides of the heart.