Letter to the Editor Regarding "Use of Embolectomy With Local Anesthesia for Anticoagulation Failure in Radial Artery Thrombosis" by Yilmaz et al

Sir, Yilmaz et al conclude that embolectomy “can be recommended as an effective and alternative method for the medical treatment of RAT [radial artery thrombosis] after cardiac catheterization.” While the lack of morbidity in this series would suggest embolectomy at the wrist is safe, the cohort is too small to generalize. That is not to say more frequent embolectomy in such patients would lead to significant morbidity, indeed it should be a relatively simple procedure, but is it a necessary risk? The goal of management in RAT is the resolution of symptoms and return to baseline function. All 99 patients in this study achieved this with or without surgery. The authors report a greater improvement in symptom score in the surgery group, but since all patients achieved full resolution, this greater improvement is solely a function of the surgical group having worse symptoms at the outset, and we cannot infer that medically treated patients would not have achieved similar improvements if they were similarly afflicted at the outset. A more likely explanation is that surgery was easier to justify on a case by case basis for more symptomatic patients. There was no significant difference in post-treatment symptom scores so one can only conclude that both are effective. The only clear benefit of embolectomy shown in this article is the reduced follow up time. This obviously has positive implications in cutting down clinic visits etc. but these benefits must be weighed against the resource implications of surgery, even when performing a brief procedure under local anesthesia. Furthermore, we do not have any objective measure of whether embolectomy has been successful and do not know how many patients now have a patent radial artery. This can be discounted as irrelevant in day to day clinical practice because what matters is resolution of symptoms, not the method by which it is achieved, but in a study such as this an objective method of assessing recanalization would be useful. This would allow the reader to make inferences about whether embolectomy was successful in these cases, or if the resolution of symptoms has in fact occurred by the very same means as in the medical group. The timing of the improvement in patients’ symptoms is also of interest in that regard. 51 patients achieved resolution within 1 month, but none of the patients in the ongoing medical management group had any improvement over their second month of treatment and all then resolved in the third month. Perhaps a reasonable explanation for this is that early resolution can occur with recanalization, but that physiologic adaptation, such as formation of collaterals, is responsible for the later resolution. Regardless of the mechanism however, the resolution of symptoms in all cases in the medical management group within 3 months can be considered a good outcome and we cannot say this would not have been achieved had the embolectomy group had a similar period of medical management. In the title the authors refer to “Anticoagulation failure.” With so many patients achieving a satisfactory outcome at 3 months, having not had any resolution at 1 month, it seems reasonable that this tag be reserved for patients who have undergone 3 months’ medical management without resolution.