A77-year-old female with ACS, LM-triple vessel disease, LVEF 20% and a 1.8cm LVT(Figure 1), with prohibitive surgical risk and cardiac index of 1.5 L/min/m²on inotropic support, was offered percutaneous coronary intervention (PCI) withconcurrent thrombus aspiration with the AngioVAC system (AngioDynamic, USA) perheart team decision.

ECG: TWI I, V5-V6, late precordial R transitionEcho: LVEF 20%. Apical aneurysm. 1.8 LV apical thrombus. Moderate mitral regurgitatino

Elevated filling pressures. RA 10mmHg PA 52/12mmHg mean 32mmHg, PCWP 28mmHgFick Cardiac output/index 2.6 / 1.5 Coronary arteriogram: LM bifurcation medina 1,1,1 diseasemLAD subtotal occlusionpLCx 70-80% calcified lesionpRCA CTO, left-to-right collaterals

Right femoral vein access with a 26-French sheath with hemostatic valve (DrySeal, Gore Medical USA) preclosed with two proglides (Abbott Cardiovascular, USA) was obtained. Biradial accesses were used for cerebral embolic protection (figure 2, panel A). Transeptal puncture(B) and septostomy(C) followed by balloon-assisted tracking(D) brought a 22 French AngioVAC cannula into the left atrium (E), followed by mitral valve crossing to reach the LV apex via a Confida wire(G-I) (Medtronic, USA), followed by thrombectomy, all under transesophgeal echocardiography(TEE) guidance (H-J). Blood was returned through an oxygenator into a 15 French cannula place in 16 French Dryseal sheath via right femoral artery access preclosed with proglides. After thrombectomy, the suction cannula was pulled back into the right atrium with the funnel retracted. At a flow rate of 3.5 liters-per-minute , it served as a venoarterial-extracorporeal memebraneous oxygenation(VA-ECMO) circuit(figure 3, panel A). Complex high-risk indicated PCI (CHIP) was performed via left femoral artery access to left anterior descending artery(LAD), left circumflex artery(LCx) and LM bifurcation (B-P) with good result on final angiogram (figure 4, panel A). Contrast echocardiography showed no further LV thrombus (B) and unchanged mitral regurgitation (C) after the thrombus was fished out (D). The patient recovered and was discharged

Acutecoronary syndrome(ACS) with concurrent left main bifurcation disease, reduced leftventricular ejection fraction(LVEF) and left-ventricular thrombus(LVT) is achallenging situation where the microaxial flow pump for supporting coronaryintervention is contraindicated owing to embolic risk. Off-label AngioVAC use for concurrent left-sided thrombectomy and hemodynamic support for CHIP is possible. Operator proficiency with large bore access and careful cannula positioning to avoid suctioning is required