Abstract
Background
The single transradial guiding catheter (STGC) technique has emerged as a promising approach to minimize catheter exchanges and optimize reperfusion timelines in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). This study aimed to compare the procedural efficiency and clinical outcomes of two STGC-based strategies: electrocardiogram (ECG)-guided culprit-first intervention and angiography-based group.
Methods
A retrospective cohort study was conducted on 494 STEMI patients who underwent transradial PCI using a 6Fr IL3.5 (Terumo) STGC at Jiading District Central Hospital between January 2022 and December 2024. Patients were stratified into two groups based on procedural workflow: the ECG-guided group (n = 128) underwent immediate culprit vessel PCI guided by preoperative ECG followed by contralateral angiography, while the angiography-based group (n = 366) received bilateral diagnostic angiography prior to culprit vessel intervention. Primary endpoints included door-to-balloon (D2B), catheterization lab-to-balloon (C2B), and puncture-to-balloon (P2B) times. Secondary endpoints encompassed procedural success rate, 30-day major adverse cardiac events (MACE), and operator preference.
Results
The ECG-guided group demonstrated significantly shorter median C2B (20.96 vs. 23.55 min, p = 0.01) and P2B times (13.89 vs. 16.06 min, p < 0.01) compared to the angiography-based group. However, there was no statistically significant difference in D2B time between the two groups (50.46 vs. 56.44 min, p = 0.36). Both groups achieved high procedural success rates (98.43% vs. 99.18%, p = 0.68) and comparable post-PCI Thrombolysis In Myocardial Infarction flow grade(TIMI)-3 flow rates (98.44% vs. 99.18%). Culprit vessel distribution differed significantly (p < 0.001), with left anterior descending artery (LAD) predominance in the ECG-guided group (71.88%) and a more balanced distribution between right coronary artery (RCA) and LAD in the angiography-based group. Operator preference strongly influenced strategy selection (p = 0.002), with four operators showing varying inclinations towards angiography-based group (66.67∽87.18%). No significant differences were observed in 30-day MACE (cardiac death, reinfarction, target vessel revascularization) or stroke rates (all p > 0.05).
Conclusions
In STEMI patients undergoing transradial PCI with an IL3.5 single transradial guiding catheter, the ECG-guided culprit-first strategy was associated with significantly shorter C2B and P2B times compared with the angiography-based approach. However, no significant difference was observed in total D2B time between the two strategies.
Keywords: ST-elevation myocardial infarction, Primary percutaneous coronary intervention, Single transradial guiding catheter, Reperfusion time
Background
Early reperfusion therapy is important for patients with acute ST elevation myocardial infarction (STEMI). The key to reperfusion therapy is to open infarct-associated vessels (IRA) as quickly as possible [1]. Increasing numbers of studies have shown that early successful reperfusion can quickly restore coronary artery patency and reduce the incidence of acute complications [2]. During primary percutaneous coronary intervention (PCI), performing PCI on the culprit lesions before completing coronary arteriography (CAG) has been shown to be safe in patients with STEMI and results in shorter reperfusion times [3]. Emergency percutaneous coronary intervention through the radial artery (TRPCI) has replaced the femoral artery as a routine method due to its safety and lower incidence of access-related complications [1]. In transradial interventional therapy, the traditional method involves performing complete diagnostic coronary angiography with a diagnostic catheter first, then selecting a guiding catheter to complete intervention according to the IRA, which requires multiple catheter exchanges [4, 5].The radial artery is more prone to spasm than the femoral artery due to its smaller lumen diameter.Repeated catheter replacement may cause patient discomfort, radial spasm, or even radial occlusion, resulting in difficult catheter exchange or conversion to other access sites, thereby prolonging door-to-balloon (D2B) time [6–8].
Current guidelines from the European Society of Cardiology and American College of Cardiology/American Heart Association for STEMI management recommend primary PCI within 60–90 min, respectively [9]. Achieving a D2B time of 90 min or less is an important quality indicator for emergency intervention to improve prognosis [10].Many studies have focused on shortening the time from hospital arrival to catheterization laboratory, such as by bypassing the emergency department and optimizing prehospital emergency medical services (EMS) coordination with an in-house interventional team [11–14]. Directed angiography based on preoperative electrocardiogram (ECG) prediction of the IRA followed by immediate intervention may shorten D2B time, but may limit full evaluation of atherosclerosis in non-infarct-related vessels. In recent years, interest in optimizing the intra-procedural components of D2B time — specifically catheterization laboratory-to-balloon (C2B) and puncture-to-balloon (P2B) time — has gradually increased [15, 16]. Previous meta-analyses have suggested that the advantages of TRPCI might be weakened by longer C2B times [16].
Interventionists have attempted to shorten C2B and P2B times, including by using a single transradial guiding catheter (STGC) for both coronary angiography and culprit vessel PCI.Use of a STGC to complete bilateral coronary angiography and intervention simplifies the procedure, minimizes catheter use and exchanges, reduces the risk of radial spasm, and may shorten D2B time [17, 18].A previous study confirmed that the IL3.5 catheter (Ikari-Left 3.5, a 6Fr single universal guiding catheter; Terumo Corporation, Tokyo, Japan) is safe and feasible [19–22].Most studies using a STGC perform complete diagnostic angiography followed by culprit vessel PCI [23, 24], while others use ECG-guided immediate culprit intervention with a STGC [25].The two strategies have different strengths. The angiography-first approach allows full assessment of coronary anatomy, lesion extent, and collateral circulation, whereas ECG-guided immediate culprit intervention may further reduce D2B and C2B time [25].
In most previous comparative studies, the control group used a standard diagnostic catheter (such as 5Fr Tiger II) for contralateral angiography, followed by guide catheter exchange for PCI. However, in real-world practice, operators often select strategies based on personal experience and patient characteristics.
To date, real-world data comparing the two strategies using the same STGC platform remain limited. Therefore, the present study retrospectively analyzed patients undergoing emergency PCI with a STGC at Jiading District Central Hospital since 2022, and compared procedural and clinical outcomes between the ECG-guided culprit-first and angiography-first strategies.
Materials and methods
This was a retrospective observational cohort study. A total of 602 patients who entered the chest pain center for STEMI in Jiading District Central Hospital from January 2022 to December 2024 underwent direct PCI. Among these patients, 494 patients received an IL3.5 single guide catheter (Ikari-Left catheter 3.5, a 6-Fr single universal guiding catheter; Terumo Corporation, Tokyo, Japan) as the first choice for coronary angiography and interventional therapy through the radial artery approach.
Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) age > 18 years (2) patients presenting within 12 h after symptom onset with chest pain lasting > 20 min or patients still having chest pain symptoms with an onset of 12–24 h, at least two consecutive ST segment elevations > 1 mm on bedside ECG, or new left bundle branch block (3) using the IL3.5 single guide catheter (Terumo, Japan) as the first choice for coronary angiography and interventional therapy (4) PCI via the radial artery approach (5) patients signed informed consent.
Exclusion criteria were as follows: (1) severe hepatic or renal insufficiency. (2) previous coronary stent implantation or coronary artery bypass grafting. (3) non-palpable radial artery pulse or abnormal Allen’s test result. (4) cardiogenic shock requiring ECMO or intra-aortic balloon pump (IABP) support. (5) complex radial artery anatomy (tortuosity, stenosis, or hypoplasia) that would preclude safe and successful use of a single transradial guiding catheter. The study was approved by the Ethics Committee of Jiading District Central Hospital, and all patients provided written informed consent for the interventional procedure.
The Ethics Committee of Jiading District Central Hospital approved this study, and all patients provided written informed consent for intervention.
PCI procedure
All patients received 300 mg aspirin and 180 mg ticagrelor before emergency PCI. After confirming a normal Allen’s test, the right radial artery was routinely punctured, an arterial sheath was inserted, and intravenous heparin was administered at 70–100 U/kg based on body weight. The culprit vessel was pre-judged based on preoperative ECG. The IL3.5 guiding catheter was used as the first-choice device in all patients for both coronary angiography and intervention. The procedural sequence (ECG-guided culprit-first vs. angiography-first) and any catheter management were determined by the attending operator according to personal preference and clinical judgment. Intraoperative use of GP IIb/IIIa inhibitors was at the operator’s discretion. Procedures were performed by four experienced interventional cardiologists, each performing more than 100 PCIs annually. The arterial sheath was removed postoperatively unless delayed removal was indicated due to complications. Hemostasis was achieved using a TR band (Terumo, Japan) with 6–8 h of compression. All patients were prescribed dual antiplatelet therapy for at least 12 months after PCI.
Definition and observation of measurements
The D2B time is the interval between the patient’s arrival at the hospital and the first instrumental intervention (balloon, aspiration catheter, or direct stenting) applied to the culprit vessels. The C2B time is the interval between the patient’s arrival at the cathlab and the first instrumental intervention on the culprit vessels, and the P2B time is the interval between the initiation of the puncture and the first instrumental intervention in the culprit vessel. Catheter success for coronary angiography (CAG) was defined as satisfactory opacification of the left and right coronary systems using the IL3.5 catheter without additional catheter exchange, allowing adequate evaluation of coronary anatomy and culprit lesions. Catheter change during CAG was defined as any replacement of the IL3.5 guiding catheter with another diagnostic or guiding catheter to complete coronary angiography due to inadequate visualization, instability, or technical difficulty.PCI success is defined as when the blood flow of the culprit vessels at the end of the operation is thrombolysis in myocardial infarction (TIMI-3) blood flow and residual stenosis < 20%. In the absence of any adverse events, 30-day results were obtained from direct patient visit or telephone follow-up. Major adverse cardiac events (MACE) were defined as cardiac death, myocardial reinfarction, or target revascularization due to acute or subacute intra-stent thrombosis. Cardiac death is defined as death from cardiac-related causes or PCI-related or unexplained causes.
Statistical analysis
SPSS 27.0 software was used to perform all statistical analyses. We presented continuous variables with a normal distribution as mean ± SD, and a t-test was used for comparison between groups. Those with non-conformal distributions were expressed as the median (interquartile distance), and the Mann-Whitney U test was used for comparison between groups. Statistical data were presented as samples (%) and χ2 test was used for comparison between groups, and p-values < 0.05 were considered statistically significant.
In addition, multivariable linear regression analysis was performed to assess the independent association between procedural strategy and time outcomes (C2B and P2B times). The models included strategy group (ECG-guided vs. angiography-based), culprit vessel (LAD vs. non-LAD), and operator (categorical) as independent variables. Between-group differences in median times were calculated with 95% confidence intervals (CIs) using the Hodges–Lehmann estimator. A two-sided p-value < 0.05 was considered statistically significant.
Results
Baseline characteristics
The study data were provided by the Chest Pain Center of Jiading District Central Hospital. A total of 494 patients with STEMI were included, with an average age of 61.96 years, including 426 males and 68 females (Fig. 1). The average age of patients in the ECG-guided culprit-first strategy group was 60.31 years, and the average age of patients in the angiography-based group was 62.54 years, with no significant difference between the two groups (p = 0.13). Demographic characteristics showed comparable distributions between groups regarding gender (p = 0.11), height (p = 0.19), weight (p = 0.47), and current smoking status (p = 0.28). Similarly, no significant intergroup differences were observed in comorbidities, including diabetes mellitus (p = 0.07), hypertension (p = 0.49), hypercholesterolemia (p = 0.92), or family history of coronary artery disease (p = 0.60). Additionally, no significant difference was found in the distribution of onset time (time from symptom onset to intervention) between the two groups (p = 0.32). The Killip class on admission (reflecting cardiac function) was similar between the ECG-guided culprit-first strategy group and the angiography-based group. Table 1 shows the baseline characteristics of the patients.
Fig. 1.
Flow diagram of patients undergoing emergency PCI using STGC
Table 1.
Demographic and baseline characteristics of the study population
| ECG-Guided group (n = 128) | Angiography-based group (n = 366) | p-value | |
|---|---|---|---|
| Age (years) | 60.31 ± 14.51 | 62.54 ± 14.32 | 0.13 |
| Male sex, n (%) | 105 (82.03) | 321 (87.70) | 0.11 |
| Hypertension, n (%) | 75 (58.6) | 227 (62.02) | 0.49 |
| Diabetes mellitus, n (%) | 26 (20.31) | 107 (29.2) | 0.07 |
| Hypercholesterolemia, n (%) | 14 (10.9) | 39 (10.66) | 0.93 |
| Current smoking, n (%) | 69 (53.9) | 177 (48.4) | 0.28 |
| Body height (cm) | 168.96 ± 6.08 | 167.89 ± 7.10 | 0.13 |
| Body weight (kg) | 72.11 ± 11.99 | 71.38 ± 13.58 | 0.59 |
| Family history, n (%) | 1 (0.7) | 3 (0.8) | 0.60 |
| Onset time | |||
| 0–3 h, n (%) | 49 (38.28) | 120 (32.79) | |
| 3–6 h, n (%) | 26 (20.31) | 73 (19.95) | |
| 6–12 h, n (%) | 23 (17.97) | 56 (15.30) | |
| 12–24 h, n (%) | 30 (23.44) | 117 (31.97) | 0.315 |
| Killip class on admission, n (%) | |||
| I Class | 108 (84.38) | 309 (84.43) | |
| II Class | 9 (7.03) | 27 (7.38) | |
| III Class | 1 (0.78) | 5 (1.37) | |
| IV Class | 10 (7.81) | 25 (6.83) | 0.93 |
The patients were divided into two groups according to the sequence of coronary angiography and culprit vessel intervention. The angiography-based group included patients who received bilateral coronary angiography followed by PCI of the culprit vessel with a STGC; and the ECG-guided culprit-first strategy group included patients who received ECG-guided immediate intervention on the culprit vessel with a STGC and later contralateral angiography.
The angiographic images of each patient were retrospectively reviewed by two surgeons and were divided into complete (bilateral) coronary angiography (left and right coronary angiography) and incomplete coronary angiography (only unilateral angiography of the culprit vessel was completed) before PCI. The complete (bilateral) coronary angiography before PCI group enrolled the angiography-based group; and the incomplete (unilateral) coronary angiography before PCI group enrolled the ECG-guided culprit-first strategy patients. The infarct-related and PCI vessels were independently identified, and the surgical reports and internal databases were referred to. The sequence angiography of the angiography-based group is shown in Figs. 2, 3 and 4, while that of the ECG-guided culprit-first strategy group is shown in Figs. 5, 6 and 7. All of the guiding catheters shown in the figures are IL3.5.
Fig. 2.
Acute anterior ST-segment elevation myocardial infarction. A Left coronary angiography (LAD occlusion). B Right coronary angiography. C Guide wire crossing the lesion. D post-PCI angiography
Fig. 3.
Acute inferior myocardial infarction. A Left coronary angiography (LCX occlusion) (B) right coronary angiography. C guide wire crossing the lesion. D post-PCI angiography
Fig. 4.
Acute inferior myocardial infarction. A Left coronary angiography. B right coronary angiography (RCA occlusion). C guide wire crossing the lesion D post-PCI angiography
Fig. 5.
Acute extensive anterior wall myocardial infarction. A Left coronary angiography (LAD occlusion). B guide wire crossing the lesion. C post-PCI angiography. D right coronary angiography
Fig. 6.
Acute inferior myocardial infarction. A Left coronary angiography (LCX occlusion). B guide wire crossing the lesion. C post-PCI angiography. D right coronary angiography
Fig. 7.
Acute inferior myocardial infarction. A Right coronary angiography (RCA occlusion). B guide wire crossing the lesion. C post-PCI angiography. D left coronary angiography
Coronary angiography and interventional therapy
The two groups demonstrated comparable profiles in vessel anatomical characteristics (number of coronary lesions, pre-PCI TIMI flow grades) and procedural parameters (catheter replacement frequency, TIMI flow grades after PCI), with no significant differences observed (all p > 0.05) (Table 2). For culprit vessel distribution, a LAD predominance was observed (71.88%, n = 92) in the ECG-guided culprit-first strategy group, followed by right coronary artery (RCA) (17.97%, n = 23) and left circumflex artery (LCX) (10.15%, n = 13). Conversely, the angiography-based group (n = 366) demonstrated more balanced RCA involvement (42.90%, n = 157) alongside LAD lesions (46.72%, n = 171), with a comparable LCX prevalence (10.38%, n = 38). While both groups exhibited similar anatomical characteristics of culprit vessels (number of coronary lesions, pre-PCI TIMI flow grades), significant intergroup differences emerged in culprit vessel distribution (p < 0.001).
Table 2.
Procedural characteristics
| ECG-Guided group (n = 128) | Angiography-Based group (n = 366) | p-value | |
|---|---|---|---|
| Procedural success, n (%) | 126 (98.434) | 363 (99.18) | 0.68 |
| Number of coronary lesions, n (%) | |||
| 1 | 37 (28.91) | 105 (28.69) | |
| 2 | 38 (29.69) | 98 (26.78) | |
| 3 | 53 (41.41) | 163 (44.54) | 0.86 |
| Culprit artery, n (%) | |||
| LAD | 92 (71.88) | 171 (46.72) | |
| RCA | 23 (17.97) | 157 (42.9) | |
| LCX | 13 (10.15) | 38 (10.38) | < 0.001 |
| TIMI flow before PCI, n (%) | |||
| 0/1 | 109 (85.2) | 283 (77.3) | |
| 2 | 9 (7.0) | 36 (9.8) | |
| 3 | 10 (7.8) | 47 (12.8) | 0.18 |
| TIMI flow after PCI, n (%) | |||
| 0/1 | 1 (0.78) | 1 (0.27) | |
| 2 | 1 (0.78) | 2 (0.55) | |
| 3 | 126 (98.44) | 363 (99.18) | 0.74 |
| Initial success of the catheter for CAG | 125 (97.66) | 361 (98.63) | 0.716 |
| RCA success for CAG | 125 (97.66) | 361 (98.63) | 0.716 |
| LCA success for CAG | 128 (100) | 366 (100) | 1.000 |
| Catheter change during CAG, n (%) | 3 (2.34) | 5 (1.37) | 0.436 |
| Culprit vessel PCI GC change, n (%) | 3 (2.34) | 7 (1.91) | 0.714 |
| No-culprit vessel PCI, n (%) | 3 (2.34) | 7 (1.91) | 0.714 |
| Different operators, n (%) | |||
| OP#1 | 44 (34.4%) | 104 (28.4%) | |
| OP#2 | 36 (28.1%) | 72 (19.7%) | |
| OP#3 | 15 (11.7%) | 102 (27.9%) | |
| OP#4 | 33 (25.8%) | 88 (24.0%) | 0.002 |
Values are presented as the mean ± SD, n (%)
CAG Coronary angiography, LAD Left anterior descending artery, LCA Left coronary artery, LCX Left circumflex, PCI Percutaneous coronary intervention, TIMI Thrombolysis in myocardial infarction, OP Operator
In the ECG-guided culprit-first strategy group, the preoperative TIMI flow grades were 0–1 in 109 patients, grade 2 in nine patients, and grade 3 in ten patients. In the angiography-based group, 283 patients had TIMI 0–1, 36 had grade 2, and 47 had grade 3. The two strategies (ECG-guided vs. angiography-based) demonstrated similar effects on postoperative coronary blood flow, with high proportions of TIMI grade 3 flow (99.18% vs. 98.44%).
The two groups showed no significant differences in the success rates of left and right coronary angiography performed using the IL3.5 catheter (Table 2). Additionally, no differences were observed in the need for catheter exchange during angiography or PCI procedures. In the angiography-based group, catheter replacements were required in five cases during angiography: one patient successfully underwent right coronary angiography (RCA) using a JR3.5 angiographic catheter, three patients received MED-SAL0.75 catheters for RCA visualization, and one patient required non-selective RCA angiography with a PIG catheter. During the PCI phase, seven patients required catheter adjustments: two adopted BL3.0 guiding catheters for LAD PCI due to anatomical constraints (small left sinus), while five transitioned to MED-SAL0.75 guiding catheters for RCA interventions. Among the latter, three cases involved failed RCA ostium engagement with initial IL3.5 catheters, prompting post-angiography MED-SAL0.75 deployment, and two cases required substitution due to inadequate backup support from IL3.5 catheters.
In the ECG-guided culprit-first strategy group, catheter replacements were required in three cases during angiography: two patients underwent selective RCA using JR3.5 catheters, while one patient underwent non-selective RCA angiography with a PIG catheter. During PCI, three patients required catheter adjustments. One patient required an upgrade to a JR3.5 guiding catheter for RCA intervention. In two LAD PCI procedures, inadequate support from IL3.5 guiding catheters prompted exchanges to ensure procedural success-replacement with an ASAHI-SBP3.5 (Asahi, Inc. Japan) catheter in one instance and a MED-EBU3.5 (Medtronic, Inc. America) catheter in the other. Furthermore, the rates of simultaneous treatment of non-culprit vessels were comparable between the groups.
Time Interval
During the study period, a total of 494 cases were included, with a median D2B time of 53.00 min. The average D2B time of patients in the ECG-guided culprit-first strategy group was 50.74 min, and the average D2B time of patients in the angiography-based group was 56.52 min. The overall data did not meet a normal distribution, and a non-parametric test was adopted. The D2B time of the two groups was not statistically significant (p = 0.36).
The median C2B time of all patients was 22.00 min, the mean C2B time of patients in the ECG-guided culprit-first strategy group was 21.12 min, and the mean C2B time of patients in the angiography-based group was 23.72 min, which did not meet a normal distribution as a whole. The non-parametric test was used, and the time difference between the two groups was statistically significant (p = 0.01).
The median P2B time of all patients was 14.5 min, the average P2B time of patients in the ECG-guided culprit-first strategy group was 13.90 min, and the average P2B time of patients in the angiography-based group was 16.17 min, which did not meet a normal distribution as a whole. The non-parametric test was used, and the difference in time between the two groups was statistically significant (p < 0.01). The treatment times (C2B time, P2B time, and D2B time) are shown in Table 3.
Table 3.
Treatment times
| ECG-Guided group (n = 128) | Angiography-based group (n = 366) | p-value | |
|---|---|---|---|
| C2B time (min) | 21 (18–24) | 24 (18– 28) | 0.01 |
| P2B time (min) | 14 (10–16) | 16 (12–19) | 0.01 |
| D2B time (min) | 50 (30– 65) | 56 (40–69) | 0.36 |
| D2B ≤ 90 min | 123 (96.10) | 348 (95.08) | 0.639 |
| D2B ≤ 60 min | 95 (74.21) | 263 (71.86) | 0.603 |
Values are presented as the median (25th, 75th percentiles) or n (%)
C2B Catheterization laboratory door-to-balloon, D2B Door-to-balloon, P2B Puncture-to-balloon
In the total STEMI study population, 95.34% of patients had a D2B time ≤ 90 min and 72.47% had a D2B time ≤ 60 min. The D2B time reaching the standard did not differ significantly between the two groups (Table 3). The results of the multivariable linear regression analysis for C2B and P2B times are presented in Table 4 .After adjusting for culprit vessel location and operator identity, the ECG-guided strategy remained independently associated with significantly shorter C2B and P2B.
Table 4.
Multivariable linear regression analysis for C2B and P2B times
| Variable | C2B Time (minutes) | P2B Time (minutes) | ||
|---|---|---|---|---|
| β (95% CI) | p-value | β (95% CI) | p-value | |
| Strategy (ECG-guided vs. Angiography-based) | -3.02 (-4.81,-1.23) | 0.001 | -2.87 (-4.39,-1.35) | < 0.001 |
| Culprit Vessel (LAD vs. non-LAD) | -1.48 (-3.18, 0.22) | 0.087 | -1.13 (-2.57, 0.31) | 0.123 |
| Operator (ref = OP#2) | ||||
| OP#1 | 0.39 (-2.08,2.86) | 0.756 | 0.62 (-1.47, 2.71) | 0.561 |
| OP#3 | -0.61 (-3.10,1.88) | 0.630 | -0.18 (-2.29, 1.93) | 0.867 |
| OP#4 | -0.31 (-2.73,2.11) | 0.802 | -0.10 (-2.16, 1.96) | 0.925 |
| Model R² | 0.041 | 0.040 | ||
| Model p-value | 0.003 | 0.003 | ||
Clinical outcomes
The incidence of MACE, including cardiac death, myocardial reinfarction, and target vessel revascularization within 30 days after emergency PCI, was not significantly different between the two groups (p > 0.05) (Table 5). The incidence of stroke between the two groups 30 days after the operation did not differ significantly between the groups, and no catheter-associated coronary complications were observed in either group.
Table 5.
Thirty-day clinical outcomes
| ECG-Guided group (n = 128) | Angiography-based group (n = 366) | ||
|---|---|---|---|
| 30 days MACE, n (%) | 5 (3.91) | 15 (4.10) | 1.000 |
| Cardiac death, n (%) | 2 (1.56) | 10 (2.73) | 0.736 |
| Reinfarction, n (%) | 3 (2.34) | 5 (1.37) | 0.421 |
| TVR, n (%) | 3 (2.34) | 4 (1.09) | 0.394 |
| Stroke, n (%) | 0 (0.00) | 2 (0.55) | 0.558 |
Values are presented as n (%)
MACE Major adverse cardiac events, TVR Target vessel revascularization
Sensitivity analysis
To address the imbalance in culprit vessel distribution, we performed a subgroup analysis restricted to patients with LAD culprit lesions (n = 263). In this cohort, the ECG-guided strategy remained associated with significantly shorter C2B time (median 21 vs. 24 min, difference − 2.00 min, 95% CI: -4.00 to -1.00, p = 0.009) and P2B time (median 14 vs. 16 min, difference − 2.00 min, 95% CI: -4.00 to -1.00, p = 0.008). confirming that the observed time reduction is not solely attributable to the overrepresentation of LAD lesions in the ECG-guided group.
Discussion
For STEMI, emergency interventional therapy is the preferred strategy, optimizing the process to minimize D2B. In our study, all patients were divided into two groups according to the sequence of angiography and intervention. In one group, patients received bilateral diagnostic coronary angiography followed by culprit vessel PCI with a STGC, while the other group received ECG-guided immediate intervention on the culprit vessel with a STGC. Retrospective analysis showed that the success rate of single catheter intervention was > 98%.
Early and sufficient opening of the IRA and restoration of forward blood flow can save the dying myocardium, reduce the infarct size, reduce mortality, and improve the prognosis for acute myocardial infarction. Emergency PCI has become the preferred method for acute myocardial infarction (AMI) treatment. Shortening the D2B time has been a concern in the emergency intervention strategy. With the deepening of the understanding of acute myocardial infarction and the construction of EMS, multi-links time from pre-hospital to cardiac catheter room have been further compressed, and the total ischemic time has been significantly shortened. At present, TRPCI has replaced the femoral artery as the preferred route due to its good safety. However, early studies have found that the RA route may reduce the target rate of D2B time [26–28]. In addition to radial artery spasm, puncture difficulties and upper limb artery tortuosity are other factors that warrant consideration. To overcome the disadvantages of the radial artery pathway, some centers have attempted to explore the possibility of shortening the operation time to further shorten the D2B time and improve the outcome of STEMI by innovating the PCI procedure strategy. The single guide catheter technique is an innovative technique that uses one guide catheter for imaging and PCI, which, compared with traditional surgery, can save five steps: two catheter exchanges, two catheter removals from non-IRA, and one catheter exchange. The unique shape and material of the IL catheter enable the use of a single guide catheter to complete the left and right coronary artery imaging and interventional therapy.
Removing the requirement for catheter exchange can reduce the occurrence of radial artery spasm, shorten the coronary artery recanalization time and operation time, and reduce the surgical cost. Moon et al. [26] used a single guide catheter to complete PCI, with a success rate of 96.7% and a D2B compliance rate that significantly increased to 74.2% within 90 min. This was mainly attributed to the simplification of surgical procedures and the shortening of P2B time (p = 0.001). Chow et al. [27] confirmed the safety and superiority of using the IL3.5-guided catheter technique through the radial artery approach for angiography and interventional treatment of patients with STEMI compared with the traditional femoral artery approach. Other studies have shown that the C2B and D2B can be further shortened using ECG as a means to predict culprit blood vessels, and lateral angiography and simultaneous opening of culprit blood vessels can be performed first. Studies have also shown that a 10-min reduction in D2B time can significantly reduce the risk of postoperative death. Guo et al. reported that ECG-guided immediate intervention on the culprit vessel with a STGC could reduce the C2B by 7.2 min, and achieve the D2B goal time within 90 min by 93.9% of cases.
Our center routinely uses a single guide catheter (IL3.5) to complete coronary angiography and interventional therapy in patients with acute STEMI. The interventional cardiologist must decide whether to complete angiography-based group first or give priority to angiography and interventional therapy of culprit vessels. In this retrospective analysis, we found that the group that received ECG-guided immediate intervention on the culprit vessel with a STGC had shorter C2B and P2B times than the group that received complete first with a STGC. The total D2B time did not differ significantly between the two groups. These findings demonstrate that the current single-catheter strategies are not sufficient to modify the D2B time. The Minimum Clinically Important Difference (MCID) is the smallest meaningful endpoint change justifying clinical practice adjustment. For STEMI, MCID for reperfusion times depends on improved hard outcomes (e.g., mortality, 30-day MACE), not arbitrary cutoffs. Our ~ 3-minute C2B and ~ 2-minute P2B reductions did not improve D2B time or 30-day MACE, failing to meet MCID and leaving the strategy’s clinical value unproven.
In addition, in patients with acute anterior wall myocardial infarction, the proportion of culprit vessels preferentially treated according to ECG-guided was higher, whereas the number of culprit vessels preferentially treated according to ECG was lower in patients with acute inferior myocardial infarction. The anterior myocardial infarction was caused by occlusion of the left anterior descending branch, whereas inferior myocardial infarction was mostly caused by right coronary occlusion, and a small part was caused by left circumferential branch occlusion. Anterior wall myocardial infarction was more accurate in predicting culprit blood vessels by ECG, whereas inferior wall myocardial infarction could be misjudged by ECG. Therefore, no vascular occlusion was found after conventional RCA when acute inferior wall myocardial infarction was predicted by ECG as right coronary occlusion, and further left coronary angiography was performed. Although a preoperative ECG may be misjudged, it still has excellent reference value in the prediction of culprit blood vessels.
For emergency interventional treatment, coronary angiography and interventional treatment are completed with a single catheter. Our 1-month follow-up data showed no significant difference between the strategies for MACE events within 30 days. However, due to the difference in preoperative conditions, further study is needed to determine whether the ECG-guided immediate intervention on a culprit vessel with a STGC can improve the prognosis of patients.
This study has several limitations. First, the study design is single-center and non-randomized. Second, the sample size is limited, which may compromise the statistical power and generalizability of the findings. While time savings may benefit high-risk STEMI subgroups (cardiogenic shock, CPA, large anterior STEMI), our limited sample size and low event rate yielded too few cardiogenic shock patients for valid subgroup analysis. This limitation is noted, with future large-scale studies needed to evaluate the strategy in this population. No effect sizes/95% CIs (limiting clinical significance assessment) and small sample size (hindering practical value of 2–3-minute C2B/P2B reduction). Additionally, improved procedural efficiency did not translate into significant changes in total ischemic time or major adverse clinical events. We did not analyze operator-specific C2B/P2B times, test operator × strategy interaction, or explore faster operators’ preferences, limiting understanding of performance differences.
Future studies should use larger multi-center samples, report effect sizes / 95% CIs, conduct long-term follow-up, and address operator-related analyses to clarify these issues.
Conclusions
The ECG-guided culprit-first strategy provides a statistically significant 2-minute reduction in C2B and P2B times, but this does not improve total D2B time or 30-day outcomes.
Acknowledgements
We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript.
Abbreviations
- CAG
Completing coronary arteriography
- ECG
Electrocardiogram
- STEMI
ST-segment elevation myocardial infarction
- STGC
Single transradial guiding catheter
- PCI
Percutaneous coronary intervention
- C2B time
Catheterization lab-to-balloon time
- P2B time
Puncture-to-balloon time
- D2B time
Door-to-balloon time
- dLAD
Left anterior descending artery
- LCX
Left Circumflex Artery
- RCA
Right coronary artery
- MACE
Major adverse cardiovascular events
- IRA
Infarct-associated vessels
- TRPCI
Transradial Percutaneous Coronary Intervention
- MCID
Minimum Clinically Important Difference
- TVR
Target vessel revascularization
Authors’ contributions
Conghui Yan participated to write the manuscript. Linglin Zhang performed the experiments. Shuang Sha participated in the experimental design. Xia Chen performed the statistical analysis. Hongsong Li and Xiangdong Xu confirmed the authenticity of all the raw data and revised the manuscript. All authors have approved the final manuscript.
Funding
This study was funded by Key Disciplines of Shanghai Health System in 2024 (2024ZDXK0027) and the Shanghai University of Medicine and Health Sciences Seed Fund (SSF-23-18-002).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The research has been performed in accordance with the Declaration of Helsinki. The present study approved by the Ethics Committee of Jiading District Central Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Shanghai, China). The Clinical Ethics Number is TH-2025-02. All the participants provided the informed signed consent document.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Conghui Yan, Linglin Zhang and Shuang Sha contributed equally to this work.
Hongsong Li and Xiangdong Xu are corresponding authors.
Contributor Information
Hongsong Li, Email: xlys_hs@qq.com.
Xiangdong Xu, Email: 18930862372@163.com.
References
- 1.Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–77. [DOI] [PubMed] [Google Scholar]
- 2.Zhao L, Xin M, Piao X, Zhang S, Li Y, Cheng XW. Prognostic Implications of the Admission Cardiac Troponin I Levels and Door-to-Balloon Time on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Ther Clin Risk Manag. 2022;18:31–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Levi N, Wolff R, Jubeh R, Shuvy M, Steinmetz Y, Perel N, Maller T, Amsalem I, Hitter R, Asher E, et al. Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(3):e243729. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kim SM, Kim DK, Kim DI, Kim DS, Joo SJ, Lee JW. Novel diagnostic catheter specifically designed for both coronary arteries via the right transradial approach. A prospective, randomized trial of Tiger II vs. Judkins catheters. Int J Cardiovasc Imaging. 2006;22(3–4):295–303. [DOI] [PubMed] [Google Scholar]
- 5.Caputo RP, Tremmel JA, Rao S, Gilchrist IC, Pyne C, Pancholy S, Frasier D, Gulati R, Skelding K, Bertrand O, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv. 2011;78(6):823–39. [DOI] [PubMed] [Google Scholar]
- 6.Shroff AR, Gulati R, Drachman DE, Feldman DN, Gilchrist IC, Kaul P, Lata K, Pancholy SB, Panetta CJ, Seto AH, et al. SCAI expert consensus statement update on best practices for transradial angiography and intervention. Catheter Cardiovasc Interv. 2020;95(2):245–52. [DOI] [PubMed] [Google Scholar]
- 7.Singh S, Singh M, Grewal N, Khosla S. The fluoroscopy time, door to balloon time, contrast volume use and prevalence of vascular access site failure with transradial versus transfemoral approach in ST segment elevation myocardial infarction: A systematic review & meta-analysis. Cardiovasc Revasc Med. 2015;16(8):491–7. [DOI] [PubMed] [Google Scholar]
- 8.Le May M, Wells G, So D, Chong AY, Dick A, Froeschl M, Glover C, Hibbert B, Marquis JF, Blondeau M, et al. Safety and Efficacy of Femoral Access vs Radial Access in ST-Segment Elevation Myocardial Infarction: The SAFARI-STEMI Randomized Clinical Trial. JAMA Cardiol. 2020;5(2):126–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):485–510. [DOI] [PubMed] [Google Scholar]
- 10.Task Force on the management of STseamiotESoC, Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569–619. [DOI] [PubMed] [Google Scholar]
- 11.Pulia M, Salman T, O’Connell TF, Balasubramanian N, Gaines R, Shah F, Henry M, Leya F, Mathew V, Bufalino D, et al. Impact of Emergency Medical Services Activation of the Cardiac Catheterization Laboratory and a 24-Hour/Day In-Hospital Interventional Cardiology Team on Treatment Times (Door to Balloon and Medical Contact to Balloon) for ST-Elevation Myocardial Infarction. Am J Cardiol. 2019;124(1):39–43. [DOI] [PubMed] [Google Scholar]
- 12.McLaren JTT, Kapoor M, Yi SL, Chartier LB. Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion. J Emerg Med. 2021;60(1):25–34. [DOI] [PubMed] [Google Scholar]
- 13.Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, et al. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association’s Mission: Lifeline Program. J Am Heart Assoc. 2020;9(2):e011963. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308–20. [DOI] [PubMed] [Google Scholar]
- 15.Diercks DB, Kontos MC, Chen AY, Pollack CV Jr., Wiviott SD, Rumsfeld JS, Magid DJ, Gibler WB, Cannon CP, Peterson ED, et al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009;53(2):161–6. [DOI] [PubMed] [Google Scholar]
- 16.Torii S, Fujii T, Murakami T, Nakazawa G, Ijichi T, Nakano M, Ohno Y, Shinozaki N, Yoshimachi F, Ikari Y. Impact of a single universal guiding catheter on door-to-balloon time in primary transradial coronary intervention for ST segment elevation myocardial infarction. Cardiovasc Interv Ther. 2017;32(2):114–9. [DOI] [PubMed] [Google Scholar]
- 17.Roberts EB, Wood A. Use of a single Q guide catheter for complete assessment and treatment of both coronary arteries via radial access during acute ST elevation myocardial infarction: a review of 40 consecutive cases. J Interv Cardiol. 2011;24(5):389–96. [DOI] [PubMed] [Google Scholar]
- 18.Malaiapan Y, Leung M, Ahmar W, Hutchison AW, Prasad S, Katticaran T, Cameron JD, Harper RW, Meredith IT. Guideline recommended door-to-balloon time can be achieved in transradial primary PCI–the usefulness of a dedicated radial guide catheter. Cardiovasc Revasc Med. 2013;14(1):27–31. [DOI] [PubMed] [Google Scholar]
- 19.Youssef AA, Hsieh YK, Cheng CI, Wu CJ. A single transradial guiding catheter for right and left coronary angiography and intervention. EuroIntervention. 2008;3(4):475–81. [DOI] [PubMed] [Google Scholar]
- 20.Murakami T, Masuda N, Torii S, Ijichi T, Natsumeda M, Fujii T, Nakano M, Ohno Y, Nakazawa G, Shinozaki N, et al. The Efficacy and Feasibility of Chronic Total Occlusion by Transradial Intervention: A Japanese Single-Center Retrospective Study. J Invasive Cardiol. 2015;27(9):E177–181. [PubMed] [Google Scholar]
- 21.Ikari Y, Nagaoka M, Kim JY, Morino Y, Tanabe T. The physics of guiding catheters for the left coronary artery in transfemoral and transradial interventions. J Invasive Cardiol. 2005;17(12):636–41. [PubMed] [Google Scholar]
- 22.Ikari Y, Masuda N, Matsukage T, Ogata N, Nakazawa G, Tanabe T, Morino Y. Backup force of guiding catheters for the right coronary artery in transfemoral and transradial interventions. J Invasive Cardiol. 2009;21(11):570–4. [PubMed] [Google Scholar]
- 23.Lee KH, Torii S, Oguri M, Miyaji T, Kiyooka T, Ono Y, Asada K, Adachi T, Takahashi A, Ikari Y. Reduction of door-to-balloon time in patients with ST-elevation myocardial infarction by single-catheter primary percutaneous coronary intervention method. Catheter Cardiovasc Interv. 2022;99(2):314–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Guo J, Chen W, Wang G, Liu Z, Hao M, Xu M, Zhu F. Safety and Efficacy of Using a Single Transradial MAC Guiding Catheter for Coronary Angiography and Intervention in Patients with ST Elevation Myocardial Infarction. J Interv Cardiol. 2017;30(1):33–42. [DOI] [PubMed] [Google Scholar]
- 25.Couture EL, Berube S, Dalery K, Gervais A, Harvey R, Nguyen M, Parenteau E, Daneault B. Culprit Vessel Revascularization Prior to Diagnostic Angiography as a Strategy to Reduce Delays in Primary Percutaneous Coronary Intervention: A Propensity-Matched Analysis. Circ Cardiovasc Interv. 2016;9(5):e003510. [DOI] [PubMed] [Google Scholar]
- 26.Moon KW, Kim JH, Kim JY, Jung MH, Kim GH, Yoo KD, Kim CM. Reducing needle-to-balloon time by using a single guiding catheter during transradial primary coronary intervention. J Interv Cardiol. 2012;25(4):330–6. [DOI] [PubMed] [Google Scholar]
- 27.Chow J, Tan CH, Tin AS, Ong SH, Tan VH, Goh YS, Gan HW, Tan KS, Lingamanaicker J. Feasibility of transradial coronary angiography and intervention using a single Ikari left guiding catheter for ST elevation myocardial infarction. J Interv Cardiol. 2012;25(3):235–44. [DOI] [PubMed] [Google Scholar]
- 28.Plourde G, Abdelaal E, Bataille Y, MacHaalany J, Dery JP, Dery U, Larose E, De Larochelliere R, Gleeton O, Barbeau G, et al. Effect on door-to-balloon time of immediate transradial percutaneous coronary intervention on culprit lesion in ST-elevation myocardial infarction compared to diagnostic angiography followed by primary percutaneous coronary intervention. Am J Cardiol. 2013;111(6):836–40. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.