This live case features a 42-year-old male on dialysis with end-stage kidney disease as well as diabetes and other cardiovascular risk factors. Operators Ziad Ali, MD, and Allen Jeremias, MD, perform Impella-supported PCI on several vessels with the goal of complete revascularization. Panelists Paul Teirstein, MD, and Duane Pinto, MD provide lively discussion. The case highlights the use of IVUS to minimize contrast and benefits of Impella® support in a challenging, complex case.