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Page 8 of 10 Dall’Ara et al. Vessel Plus 2023;7:26 https://dx.doi.org/10.20517/2574-1209.2023.107

technical method in such complex procedures, is an additional point of comparison.

Of note, despite not reaching statistical significance, our analysis found a lower failure rate with the use of
an SGC than the standard transradial technique, which consists of using a guiding catheter placed through a
vascular sheath. Conversely, in this real-world setting of complex patients, the femoral approach allowed
coronary RA to be performed in all the attempted cases. The average rate of radial access failure (10.7%)
requiring vascular crossover was slightly higher than in a large randomized trial, likely due to different
baseline characteristics in patients, our population being older, with a higher prevalence of peripheral
[9]
vascular disease, and selected because of extensive coronary calcifications . Transradial failure was mainly
due to faint radial pulse, radial artery occlusion or narrowing, or tortuous anatomy of the subclavian artery.
We must highlight that operators often prefer to perform complex procedures using a size ≥ 7 French
catheter, with possible limitations deriving from the bulky size and stiffness of the device. Indeed, a smooth,
iodophilic, and less bulky SGC may overcome several trackability issues and, at the same time, ensure
sufficient backup during the procedure. This may explain the slight advantage observed in our analysis of
using an SGC. On the other hand, there was only one case of crossover from SGC to the standard radial
approach in order to improve catheter support during PCI.

When the transradial approach was feasible, this study confirmed that RA procedures via an SGC are as
effective and safe as those performed through standard femoral and radial access. Finally, we confirmed the
tendency towards reduced bleeding in the transradial approach compared to the transfemoral, with clear
clinical implications [1].

Of note, the referral of patients with extensive coronary calcifications for revascularization has increased
over time due to the aging of the population, as well as the high prevalence of chronic renal failure and
[10]
diabetes mellitus . The SGC represents a viable option to handle complex coronary anatomies, allowing
RA to be performed with sufficient backup, accommodating multiple devices, and reducing forearm and
proximal vasculature stress.

Study limitations
The study is not devoid of potential bias, given its observational nature. Some differences in the baseline
characteristics of the population are typical of a retrospective study, and we cannot estimate how much they
influenced the choice of vascular access, the technique applied, and the procedural outcome. Longer
procedural time in the transfemoral group may be due to the need for an echo-guided puncture or to time-
consuming hemostasis. While more frequent use of MCS may have played a role in the 10-minute
difference in median duration, the same cannot be said for varying complexity in the coronary anatomy
[Table 2]. The main indication for MCS use was to perform a “protected PCI” in case of a combination of
left main stem involvement, low ejection fraction, last remaining vessel, and multivessel disease.

Moreover, due to the limited population size, rare events may be underrepresented and the potential
advantage of one approach over the others may not emerge significantly. Given the lack of statistical
significance in the numerical advantage we observed in PCI feasibility using an SGC, larger studies are
required to confirm the hypothesis of a possible benefit of SGC use over the standard radial approach.

We acknowledge that long-term follow-up was not available in 9.9% of patients. On the one hand, this is in
line with many observational studies, and on the other hand, long-term survival was a secondary outcome.