73 year old male with extensive PAD, s/P PTA presented with CCS Class II angina and high risk positive SPECT MPI for anterior and inferior ischemia done as the part of the pre-op evaluation for lower limb vascular surgery. A Cardiac Cath on April 10, 2019 revealed II Vessel CAD: 100% prox RCA fills via collaterals for LCx, 80-90% calcified angulated lesion of prox-mid LAD with SYNTAX Score of 23, severe LV dysfunction and LVEF 30%. Patient is now planned for Protected PCI of complex calcified LAD using orbital atherectomy and DES with LV Impella assist.