Ernesto Ruiz-Rodriguez, MD, and Tom Conley, MD, perform this live Protected PCI case from Baptist Health Heart Institute in Little Rock, Arkansas. The patient is an 81-year-old male with worsening dyspnea on exertion who has chronic kidney disease, worsening ejection fraction, severe peripheral artery disease, and very limited vascular access options. The case features percutaneous axillary access, rotational atherectomy, and right heart catheterization, as well as Impella weaning and large bore closure. Seth Bilazarian, MD, with panelists John Lasala, MD, Michael Kim, MD, and Jason Wollmuth, MD provide insightful commentary.