Single catheter strategy for transradial angiography and primary percutaneous coronary intervention enhances procedural efficiency, microvascular outcomes, and cost-effectiveness: Implications for STEMI healthcare in resource-limited settings

Mohajit Arneja; Swetharajan Gunasekar; Dharaneswari Hari Narayanan; Joshma Joseph; Harilalith Kovvuri; Sharath Shanmugam; Pavitraa Saravana Kumar; Asuwin Anandaram; Vinod Kumar Balakrishnan; Jayanty Venkata Balasubramaniyan; Sadhanandham Shanmugasundaram; Sankaran Ramesh; Nagendra Boopathy Senguttuvan

doi:10.1371/journal.pone.0337841

Peer Review History

Original SubmissionJuly 19, 2025
3 Sep 2025 Decision Letter - Sana Sheikh, Editor Dear Dr. Senguttuvan, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Reviewer #1: The study primarily focuses on outcomes that have already been established in the past, while myocardial blush grade (MBG) serves as a secondary outcome measure. Notably, the difference in MBG between the groups is more robust and hardly explained by time difference, which warrants further clarification and explanation. Reviewer #2: Thank you for giving me a chance to review the article. Overall, this is a well written article on the significance of using single universal catheter also known as IL guiding catheter in patients presenting with STEMI in a lower middle-income country. The author has critically emphasized the importance of time saving strategies like this one to improve the outcome of patients with STEMI. I have some minor comments and queries which i am sharing for the authors response 1. Methodology: line 134-141 is a little confusing. What i understand from authors message is it is a retrospective study and an ERC exemption was obtained. But in the methodology part the author says the control arms that is CTC were enrolled prospectively? This needs clarification and if this is the case was a separate ERC obtained during that period? Table 4: please use the term CTC to show the consistency in the manuscript. Please remove the sign> in p value 0.9 Discussion: Please reduced to six paragraphs. Use main headings as subheadings. In the current stat the discussion is too lengthy. Please submit your revised manuscript by Oct 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Sana Sadiq Sheikh Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. In the online submission form, you indicated that [The raw data underlying the results presented in the study are available from the corresponding author upon reasonable request.]. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: Editor comments: 1. Please mention ERC number. 2. Be consistent with the terminologies. The terminologies for the catheters is different in Table 4. 3. First paragraph of discussion should summarize the key findings. Currently it has background literature. The reference to tables is not needed when summarizing the results in discussion. 4. The claim "first study" has been contraindicated by the subsequent information provided in the discussion. The authors have referred to multiple studies that have compared the intervention outcomes between two catheters. 5. Please justify the selection of patients of the UGC group from a single operator. Also, how will you address this selection bias. It is one operator vs. eight operators. Reviewer #1: The study primarily focuses on outcomes that have already been established in the past, while myocardial blush grade (MBG) serves as a secondary outcome measure. Notably, the difference in MBG between the groups is more robust and hardly explained by time difference, which warrants further clarification and explanation. Reviewer #2: Thank you for giving me a chance to review the article. Overall, this is a well written article on the significance of using single universal catheter also known as IL guiding catheter in patients presenting with STEMI in a lower middle-income country. The author has critically emphasized the importance of time saving strategies like this one to improve the outcome of patients with STEMI. I have some minor comments and queries which i am sharing for the authors response 1. Methodology: line 134-141 is a little confusing. What i understand from authors message is it is a retrospective study and an ERC exemption was obtained. But in the methodology part the author says the control arms that is CTC were enrolled prospectively? This needs clarification and if this is the case was a separate ERC obtained during that period? Table 4: please use the term CTC to show the consistency in the manuscript. Please remove the sign> in p value 0.9 Discussion: Please reduced to six paragraphs. Use main headings as subheadings. In the current stat the discussion is too lengthy. [Note: HTML markup is below. Please do not edit.] 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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The study primarily focuses on outcomes that have already been established in the past, while myocardial blush grade (MBG) serves as a secondary outcome measure. Notably, the difference in MBG between the groups is more robust and hardly explained by time difference, which warrants further clarification and explanation Reviewer #2: Thank you for giving me a chance to review the article. Overall, this is a well written article on the significance of using single universal catheter also known as IL guiding catheter in patients presenting with STEMI in a lower middle-income country. The author has critically emphasized the importance of time saving strategies like this one to improve the outcome of patients with STEMI. I have some minor comments and queries which i am sharing for the authors response 1. Methodology: line 134-141 is a little confusing. What i understand from authors message is it is a retrospective study and an ERC exemption was obtained. But in the methodology part the author says the control arms that is CTC were enrolled prospectively? This needs clarification and if this is the case was a separate ERC obtained during that period? Table 4: please use the term CTC to show the consistency in the manuscript. Please remove the sign> in p value 0.9 Discussion: Please reduced to six paragraphs. Use main headings as subheadings. In the current stat the discussion is too lengthy. ****** 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 #1: Yes: Asadullah Bugti Reviewer #2: Yes: Farhala Baloch ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0337841.r001
Revision 1
16 Sep 2025 Author Response We would like to thank the reviewers, Dr. Asadullah Bugti (Reviewer #1) and Dr. Farhala Baloch (Reviewer #2), as well as the Academic Editor, Dr. Sana Sadiq Sheikh for their valuable and insightful comments on our manuscript titled “Single Catheter Strategy for Transradial Angiography and Primary Percutaneous Coronary Intervention Enhances Procedural Efficiency, Microvascular Outcomes, and Cost-Effectiveness: Implications for STEMI Healthcare in Resource-Limited Settings”. We have carefully reviewed all the suggestions and drafted a point-by-point response below. Reviewer Comments Reviewer #1 1) The study primarily focuses on outcomes that have already been established in the past, while myocardial blush grade (MBG) serves as a secondary outcome measure. Notably, the difference in MBG between the groups is more robust and hardly explained by time difference, which warrants further clarification and explanation. Author's Response: We thank the reviewer for their comment. While many outcomes included in our study have indeed been explored previously in various studies, our study explicitly aims to look at the clinical implications of procedural optimization in the context of PCI for STEMI patients. Prior studies have explored the impact of various procedural strategies on restoring epicardial flow, but few have looked at the concomitant impact on downstream coronary microcirculation. To this end, we agree with the Reviewer that the difference in myocardial blush grade (MBG) might be influenced by factors other than the 7-minute difference alone. Indeed, we included several hypotheses to explain the observed difference in the original manuscript. These clarifications can be found in Lines 391-399 in the Discussion section. Given that it is a pilot study, we also included a detailed explanation of the limitations in the current research, where we argue that patients with better MBG could have had shorter door-to-balloon times, which aligns with evidence from the current literature, and that quantification of microvascular perfusion by angiography alone might not be sufficient. This is highlighted in Line 520-534 in the Limitations and future directions subsection of the Discussion Section in the revised manuscript. Overall, we agree with the reviewer’s comments and would like to emphasize that we clarified the role of various confounding factors in the original manuscript and we transparently acknowledged the limitations of relying on MBG alone as a surrogate marker of microvascular perfusion. However, the results of our pilot study certainly merit further exploration, and we plan on measuring the impact of catheter strategy on microvascular perfusion by using cardiac magnetic resonance imaging (CMR) within 7 days post-PCI in a prospective, randomized trial (FASTER-PCI) that we referenced in our manuscript. Reviewer #2 1) Methodology: line 134-141 is a little confusing. What i understand from authors message is it is a retrospective study and an ERC exemption was obtained. But in the methodology part the author says the control arms that is CTC were enrolled prospectively? This needs clarification and if this is the case was a separate ERC obtained during that period? Author’s Response: We thank the Reviewer for their comment. We agree that the term “enrolled” could cause confusion and imply that the study was conducted prospectively. Therefore, we would like to emphasize that our study was retrospective in nature, and that we included data from 51 consecutive STEMI patients in the CTC cohort, in order to match the sample size of 51 patients in the UGC group. We have slightly altered the wording in the manuscript to reflect this change, which can be found in Lines 137-144 in the revised manuscript and is highlighted in red. 2) Table 4: please use the term CTC to show the consistency in the manuscript. Please remove the sign> in p value 0.9 Author’s Response: Thank you for catching the oversight with respect to terminologies. The cohort classification for Table 4 has been modified as UGC and CTC and the changes are highlighted in red in the revised manuscript. We have also removed the > sign for p-values. 3) Discussion: Please reduce to six paragraphs. Use main headings as subheadings. In the current state the discussion is too lengthy. Author’s Response: We thank the reviewer for their suggestion. Although we agree that the discussion is lengthy, we firmly believe that each subheading and the information contained within it provides the necessary context required for satisfactory interpretation of the findings of our study. We have made deliberate efforts to contextualize each relevant finding against the literature and have included detailed insights to support our defense of the data on multiple levels. The scope of our study is evident from its title and warrants a detailed evaluation of the benefits of the single catheter strategy across procedural and economic fronts. Further, we present convincing evidence which highlights that the vast majority of operators around the world still utilize separate catheters for angiography and PCI, and the uptake of universal catheters remains low, despite the temporal advantages. Lastly, we not only emphasize the novelty of our findings, but we also clearly emphasize the limitations of the current research across multiple variables and justify the need for a prospective, randomized controlled trial. Combined with the fact that PLOS One does not mandate any word limits and instead prioritizes transparent and robust communication of our findings, we have chosen to retain the ‘Discussion’ as it currently stands. Editor’s Comments 1) Please mention the ERC number. Author’s Response: Thank you for the suggestion. The ethics statement and ethics committee approval number have now been included in the Methods section and have been removed from any other section in which they were originally included. The changes can be found in Lines 108-111 in the Study Design subsection of the Methods Section and are highlighted in red font. 2) Be consistent with the terminologies. The terminologies for the catheters is different in Table 4. Author’s Response: We thank the Editor for catching our oversight with respect to terminologies. This mistake has been corrected in the revised manuscript and the new table headings for Table 4 are highlighted in red. 3) First paragraph of discussion should summarize the key findings. Currently it has background literature. The reference to tables is not needed when summarizing the results in discussion. Author’s Response: We thank the Editor for their suggestion. We have modified the Discussion section to include an opening paragraph that conveys the key results from our study. These changes can be seen in Lines 327-341 in the revised manuscript. We have also removed references to the tables in the discussion section. 4) The claim "first study" has been contraindicated by the subsequent information provided in the discussion. The authors have referred to multiple studies that have compared the intervention outcomes between two catheters. Author’s Response: We would like to emphasize that our study is the first study to utilize the Fluoroscopy-to-Device (FluTD) time metric to compare the procedural efficiency of using a single guiding catheter for both diagnostic angiography and subsequent PCI versus using separate catheters for angiography and PCI, and to evaluate the impact of procedural strategy on epicardial and myocardial outcomes. All other studies that we included in our discussion differ from the present study in the aforementioned aspects. In Lines 358-373 in the manuscript, we refer to studies where a single catheter was used for diagnostic angiography to engage both the left and right coronary arteries. However, they switched to a different catheter for PCI. Therefore, these studies only utilized a single catheter for angiography and subsequently evaluated its impact on procedure time, fluoroscopy time, and contrast volume. In the present study, however, we use the same catheter for both angiography and PCI. In Lines 90-96 in the Introduction and Lines 355-358 in the Discussion, we mention that prior studies in which the Ikari catheter was utilized for both angiography and PCI failed to evaluate epicardial and myocardial outcomes. These studies only measured procedure time, fluoroscopy time, sheath-to-balloon time, and radiation exposure. However, we not only examine the impact of using a single catheter for angiography and PCI on time to device activation (FluTD time), but we also evaluate the influence of catheter strategy on meaningful clinical outcomes. 5) Please justify the selection of patients of the UGC group from a single operator. Also, how will you address this selection bias. It is one operator vs. eight operators. Author’s Response: We thank the Editor for this insightful comment. Five operators performed primary PCI using CTC strategy, of which one operator performed both CTC and UGC. We fully agree with the Editor that the UGC group suffers from selection bias. This is a key limitation of the present study, which we had acknowledged in the original manuscript. This can be found in Lines 522-527 in the Limitations and future directions subsection of the Discussion section. However, based on the results of the pilot study, we are planning on conducting a robust, prospective, multicenter randomized controlled trial to compare the procedural efficacy and efficiency of the single catheter strategy against the conventional two catheter strategy (FASTER-PCI), which we had referenced in our original manuscript. In this prospective trial, which is set to commence soon, we have included operators from various centers to mitigate operator bias and enhance the generalizability of our findings. Attachments Attachment Submitted filename: Response to Reviewers - PONE-D-25-37889.docx https://doi.org/10.1371/journal.pone.0337841.r002
14 Nov 2025 Decision Letter - Sana Sheikh, Editor Single Catheter Strategy for Transradial Angiography and Primary Percutaneous Coronary Intervention Enhances Procedural Efficiency, Microvascular Outcomes, and Cost-Effectiveness: Implications for STEMI Healthcare in Resource-Limited Settings PONE-D-25-37889R1 Dear Dr.. Senguttuvan, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Sana Sadiq Sheikh Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: (No Response) ****** Reviewer #1: (No Response) Reviewer #2: (No Response) ****** 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 #1: Yes: Dr Asadullah Bugti MBBS,FCPS,FSCAI Reviewer #2: Yes: Farhala Baloch ******** https://doi.org/10.1371/journal.pone.0337841.r003
Formally Accepted
Acceptance Letter - Sana Sheikh, Editor PONE-D-25-37889R1 PLOS ONE Dear Dr. Senguttuvan, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Sana Sadiq Sheikh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0337841.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .