PONE-D-25-28613-->-->What Role Should EBU Catheters Play in the Interventional Approach to Anomalous Right Coronary Arteries?-->-->PLOS ONE?>

Dear Dr. Gebremedhin,

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PLOS ONE

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Additional Editor Comments:

Thank you for submitting your manuscript titled “What Role Should EBU Catheters Play in the Interventional Approach to Anomalous Right Coronary Arteries?”.

The topic addresses a clinically important and technically challenging area in interventional cardiology, PCI in anomalous right coronary artery (ARCA) cases, and focuses on the use of EBU catheters, a tool that is not routinely discussed for this application. The paper presents observational data from a real-world setting, which may be of interest to interventionalists working in complex anatomical scenarios.

However, after a thorough review, I believe the manuscript requires substantial revision before it can be considered further. The concerns are outlined below:

Major Points:

Study Design Limitations

The retrospective, single-center nature of the study and the small sample size (n=17) significantly limit the generalizability of the findings. While the rarity of ARCA is understood, the conclusions currently drawn seem too definitive for what is effectively a descriptive case series.

Lack of a Control or Comparator Group

The manuscript does not include outcomes for alternative catheters such as Judkins or Amplatz, making it difficult to objectively assess the performance of EBU catheters in this setting. Without comparative data, the conclusions about efficacy are observational at best.

Selection Bias and Framing

The study only includes patients in whom EBU was used, which likely introduces selection bias. This should be more explicitly acknowledged, and the framing of EBU as a "preferred strategy" should be softened.

Absence of Statistical Analysis

No formal statistical comparisons or hypothesis testing are presented. While this may reflect the exploratory intent of the study, it reduces the scientific weight of the conclusions. Some minimal statistical analysis (e.g., Fisher’s exact test for success rates across subtypes) could strengthen the manuscript.

Overstatement of Conclusions

The conclusions suggest a clinical algorithm for catheter selection, but this implication is not justified by the data. Please revise to reflect the exploratory nature of your findings and highlight that EBU may be one useful option rather than the preferred approach.

Minor Points:

The manuscript would benefit from language polishing to reduce redundancy and improve clarity.

Figure 2 is of limited utility in its current resolution; consider providing clearer procedural images or removing if not essential.

Please review the formatting for consistency, particularly in tables and figure legends.

A more balanced discussion of prior literature (including limitations of other catheters) would be helpful.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: This is a well-written retrospective study exploring the utility of Extra Back-Up (EBU) catheters in percutaneous coronary interventions (PCI) for anomalous right coronary artery (ARCA) cases. The topic is relevant and underreported, especially given the technical challenges these anatomical variants present. The authors provide useful subtype-specific procedural data and highlight practical implications for interventional strategy. However, there are several areas where clarity, depth, and methodological rigor could be improved.

1. The small sample size (n=17) limits the generalizability of the findings. While this reflects the rarity of the condition, a more robust discussion of how this limitation affects the study's implications is needed. Expand the limitations section to address potential selection bias, the lack of comparator groups (i.e., performance of other catheters), and how operator experience may influence outcomes.

2. The manuscript does not systematically compare the EBU catheter’s performance to other commonly used guide catheters (e.g., JR, AL, Ikari, etc.). Even if not directly studied, the authors should include more commentary in the Discussion about how EBU compares in the literature or based on their institutional experience.

3. The definitions for success (stable engagement, full device delivery, no catheter exchange) are clear, but it's not always obvious in the tables or text which patients met all components of success. Consider adding a composite procedural success column to Table 3 or clarifying directly in the Results.

4. Also, there are some minor typo errors:

Line 47: “dee to the retrospective nature...” should be “due to the retrospective nature...”

Line 201: Extra period after “achieve..”

Line 130: "10/07/2024 to 12/08/20242024" – check the formatting of the date.

Reviewer #2: Reviewer Comments on the Manuscript: "What Role Should EBU Catheters Play in the Interventional Approach to Anomalous Right Coronary Arteries?"

Congratulations to the authors on this manuscript. The study addresses an important and underrepresented topic in interventional cardiology. It offers valuable technical insights into the use of EBU catheters in managing challenging cases, specifically anomalous right coronary arteries (ARCA). The subject matter is within the scope of the journal and holds clinical relevance.

Please find below my comments and suggestions:

1. Please consider adding the type of study, for example “A Case Series” to the end of the title to clarify the study design and help set expectations for readers.

2. The manuscript requires major English language revision.

3. Ensure all abbreviations are defined upon first use in both the abstract and main text. For example, FFR (Fractional Flow Reserve) should be spelled out the first time it appears.

4. Please clarify the anatomical subtypes of patients in whom the EBU catheter was used as a second-choice guide. This detail will help strengthen the analysis across subgroups.

5. Revise the in-text citation format to match journal style. For example, “[1][2][3]” should be “[1–3]”. Refer to the journal's author guidelines and ensure consistent citation formatting throughout the manuscript.

6. On page 4, line 96, there appears to be a typographical error: “6(Figure 1)”. Please confirm whether this is an erroneous reference or formatting issue.

7. On page 5, line 117, consider revising the word “algorithm” to a more appropriate alternative such as “strategy” or “framework,”.

8. Please define your inclusion and exclusion criteria clearly. For instance, was there an age limit? Also, specify how many total patients underwent coronary angiography during the study period and how many were identified with ARCA.

9. To avoid redundancy, consider explaining the anatomical classification system either in the Methods or the Results section, but not both.

10. Tables were not visible in the version reviewed. Please ensure all tables are included in the final submission and are organized clearly according to anatomical subgroups, with baseline and procedural outcome data shown separately for each group.

11. Please clarify the study type. Since there is no comparison group, this work should be classified as a case series rather than a comparative study.

12. Consider redesigning Figure 1 to enhance visual clarity. A more simplified and illustrative schematic may help readers better understand the anatomical subtypes described.

13. There is a selection bias that should be acknowledged in the limitations section. The study includes only patients in whom the EBU catheter was attempted, and does not provide comparative data on other catheters (e.g., Amplatz, Judkins Left). This limits the generalizability of the findings.

14. Figure 2 was also not viewable. Please ensure that all figures are properly uploaded and embedded in the final version.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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What Role Should EBU Catheters Play in the Interventional Approach to Anomalous Right Coronary Arteries? A case series

PONE-D-25-28613R1

Dear Dr. Gebremedhin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Dr Redoy Ranjan, MS (CV&TS), Ch.M. (Edin), PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #2: The revised title appropriately reflects a case series, avoiding overstated claims. The success proportions (with 95% CI) and statistical comparisons (Fisher, Kruskal-Wallis) now strengthen the analytic rigor. Please be more cautious with the tables, such as the percentages of males and females that don't match. Also there are some spaces in some of the rows. Otherwise, the manuscript is significantly improved and addresses my concerns.

Reviewer #3: This exploratory study holds significant value by contributing a novel technical perspective to addressing the complex challenge of ARCA. The authors have appropriately addressed the previously noted concerns, including enhanced descriptive details and adherence to scholarly standards. Given the comprehensive clarification of the study’s limitations, this paper is now suitable for publication and will provide clinicians in the field with practical preliminary insights and a useful reference.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

Reviewer #3: No

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