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Place a large skillet over medium heat. Once skillet is hot add oil and sauté onions and garlic for 3 to 4 minutes, or until aromatics begin to slightly caramelize.
Add tomato paste and stir together. Continue to stir until paste turns bright red, 2 to 3 minutes.
Stir cream into sauce until mixture is smooth. Reduce heat to medium-low and simmer together, about 3 to 4 minutes.
Stir in butter and Parmesan and continue to simmer until sauce is smooth, glossy and has thickened enough to coat the back of a spoon, about 3 minutes.
Add ½ cup of pasta water to skillet and stir together until smooth, about 1 minute. Season with salt and pepper.
Deglaze skillet with vodka and stir together until vodka evaporates.
Add cooked pasta to sauce and toss together until fully coated.
Serve with more grated Parmesan.