Bring a large pot of salted water to a boil. Add the paccheri pasta and cook until al dente, about 10-12 minutes, stirring occasionally.

In a large skillet, heat 2 tablespoons of olive oil over medium heat. Add minced garlic and sauté until fragrant, about 1 minute.

Add the sausage to the skillet, breaking it apart. Cook until browned, about 5-7 minutes.

Add lemon zest and juice, stirring for 30 seconds. Lower the heat and add cream, mixing thoroughly for about 2-3 minutes.

Fold in the drained pasta, adding reserved pasta water if needed for desired creaminess.

Remove from heat, serve hot, and garnish with Parmesan cheese and chili flakes.