Elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reason- able in carefully selected high-risk patients. (Level of Evidence: C) IABP counterpulsation is frequently used as an adjunct to PCI in hemodynamically unstable patients.538,539 In single-center series, the routine prophylactic use of IABP during PCI in high-risk patients was associated with lower mortality and fewer major complications compared with rescue use of IABP.540,541 In the only RCT in high-risk PCI patients (BCIS-1 [Balloon Pump-Assisted Coronary Intervention Study]),542 there was no difference in the primary composite outcome between routine and provisional use of IABP. There were also no differences in major secondary endpoints except major procedural complications (eg, prolonged hypotension, ventricular tachycardia/fibrillation, cardiopulmonary arrest), which were lower in the routine IABP group. Bleeding and access site complication rates tended to be higher in the routine IABP group. The bailout rate of IABP insertion in the provisional IABP group was 12%, mostly for procedural hypotension.542 A meta-analysis of IABP therapy in patients with STEMI did not show improved outcomes with the use of The Impella Recover LP 2.5 System (Abiomed, Aachen, Germany/Danvers, Massachusetts) is a 12.5 Fr catheter that is inserted percutaneously through a 13 Fr femoral artery sheath and placed across the aortic valve into the left ventricle, through which a transaxial blood pump provides flows of up to 2.5 L/min. 