Rescue Angioplasty After Failed Thrombolysis: Technical and Clinical Outcomes in Large Thrombolysis Trial

Objectives. We sought to assess the angiographic outcome, complication rates and clinical features of percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. Background. “Rescue angioplasty” refers to mechanical reopening of an occluded infarct-related artery (IRA) after failed intravenous thrombolysis. Although the procedure is commonly performed, dat describing its technical and clinical outcome are sparse. Early reports suggested that rescue PTC is less often successful and produces more complications than primary PTCA. Other reports have described beneficial effects of successful rescue PTC but adverse outcomes when PTC is unsuccessful. Methods. Using dat from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) angiographic substudy, we compared clinical and angiographic outcomes of 198 patients selected for rescue PTC attempt with those of 266 patients with failed thrombolysis but managed conservatively and, for reference, with those of 1,058 patients with successful thrombolysis. Results. Patients offered rescue PTC had more impaired left ventricular function than those in whom closed vessels were managed conservatively. Rescue successfully opened 88.4% of closed arteries, with 68% attaining Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. The interventions did not increase catheterization laboratory or postprocedural complication rates. Multivariate analysis identified severe heart failure to be determinant of failed rescue attempt. Successful rescue PTC resulted in superior left ventricular function and 30-day mortality outcomes, comparable to outcomes in patients with closed IRAs managed conservatively, but less favorable than in patients in whom thrombolytic therapy was initially successful. The mortality rate after failed rescue attempt was 30.4%; however, five of the seven patients who died after failed rescue PTC were in cardiogenic shock before the procedure. Conclusions. Rescue PTC tends to be selected for patients with clinical predictors of poor outcome. It is effective in restoring patency. Patients who die after failed rescue attempt are often already in extremis before the angioplasty attempt.