The Impella, a percutaneous left ventricular assist device, has been reported to minimize the risk of hemodynamic compromise and improve clinical outcomes during percutaneous coronary intervention (PCI) in complex high-risk indicated patients (CHIPs). Optical coherence tomography (OCT) provides information on calcified plaque thickness, which is helpful in determining the indication and endpoint of atherectomy during PCI for calcified lesions. However, there are few reports on OCT-guided aggressive rotational atherectomy with Impella assistance in CHIPs. A 71-year-old man on dialysis for end-stage renal failure was admitted for congestive heart failure. Transthoracic echocardiography revealed severe left ventricular systolic dysfunction, and coronary angiography performed after improvement of heart failure showed severe stenosis with heavily calcified lesions in the left main trunk (LMT) bifurcation and right coronary artery. The patient refused coronary artery bypass surgery and was revascularized using PCI. PCI was started with prophylactic Impella CP insertion because of the high risk of hemodynamic collapse. After OCT-guided rotational atherectomy with 1.5- and 2.0-mm burr toward the left anterior descending artery and left circumflex artery, respectively, double-kissing culotte stenting was performed in the LMT, and good dilation was obtained. Impella CP was removed immediately after PCI without hemodynamic compromise, and the procedure was completed.