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Dall’Ara et al. Vessel Plus 2023;7:26 https://dx.doi.org/10.20517/2574-1209.2023.107 Page 3 of 10

Procedural characteristics and definitions
All procedures were performed by trained interventional cardiologists, consistent with international
[2]
recommendations . Vascular access choice, use of intravascular imaging, stenting strategy, and
antithrombotic therapy were at the operator’s discretion. The target activated clotting time value was
between 250 and 300 s. In the standard radial or femoral approach, a 6 to 8 Fr vascular sheath was placed to
accommodate the equivalent guiding catheter. Alternatively, a 7.5 Fr SGC Eaucath™ (ASAHI Eaucath SGC;
Vascular Perspectives Ltd., Manchester, UK) was used for radial procedures.

RA was performed using the Rotablator™ or, in the last three years, the Rotapro™ Rotational Atherectomy
System (Boston Scientific, Natick, MA, USA), with a default targeted 0.5-0.6 burr-to-artery ratio, speed
between 140,000 and 170,000 rotations per minute, continuous lavage with heparinized saline, and a
pecking motion of the burr in series lasting about 10 s. A temporary pacemaker lead was placed only in the
event of a new onset of a persistent rhythm disorder [Figure 1].

Access-related feasibility was evaluated by analyzing the initial approach and technique in relation to the
subsequent need for a change in vascular access (radial vs. femoral) or device (standard vs. sheathless) in
order to engage the coronary ostium and initiate revascularization. Procedural success was defined as
coronary stenosis < 20% of the lumen diameter after successful delivery and withdrawal of the employed
[8]
[7]
devices . Bleedings were classified according to the Bleeding Academic Research Consortium (BARC) .
Study objective
The purpose of our study was to analyze procedural feasibility, final success, and complication rate,
comparing the use of a transradial sheathless catheter to the standard radial and femoral vascular approach.
Long-term survival was a secondary outcome measure.

Statistics
The population was divided according to the vascular approach in the femoral group, the standard radial
group (in both, the guiding catheter was inserted through a sheath), and the sheathless radial group.
Categorical variables were stated as numbers and percentages, continuous variables as mean and standard
deviation or median and interquartile range. Analysis was performed comparing the three groups of
2
patients, and the two transradial groups. The chi test and Fisher’s exact test were used to compare
categorical data. The T Student or Mann-Whitney rank-sum test was used for continuous variables in two
groups and analysis of variance in the case of multiple groups. Long-term survival was shown via Kaplan-
Meier curves, with differences evaluated by the log-rank test. A P value of < 0.05 was considered statistically
significant. Analyses were performed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA).

RESULTS
Two hundred twenty-three patients underwent RA PCI at the participating centers. Table 1 shows the
baseline characteristics of our cohort. Male gender was the only characteristic that was unevenly distributed
between the groups. The radial approach was preferred in the majority of cases (67.7%). Of note, 44.4% of
our patients underwent ad hoc PCI with RA when the indication was an acute coronary syndrome. Only
one-third of the whole population received double antiplatelet therapy pretreatment.

Procedural data and outcome
The feasibility analysis, based on vascular access and technique, showed a failure rate of 7.5% (3 out of 40
attempts) in the transradial sheathless cohort, 11.7% (15/128) in the standard radial, and 0.0% (0/55) in the
femoral [Figure 2]. The reason for seven of the 18 failed radial attempts was unfavorable peripheral anatomy
(e.g., faint pulse, occluded artery, remnant artery, tortuosity), while the remaining 11 cases were due to poor
backup, which also included tortuosity of the supra-aortic vessels [Figure 3].