Comment on “Real‐World Outcome of Coronary Orbital Atherectomy in Diabetic Versus Nondiabetic Patients: A Single‐Center Experience”

We read with great interest the article titled, “Real-World Outcome of Coronary Orbital Atherectomy in Diabetic Versus Nondiabetic Patients: A Single-Center Experience” by Klein et al. [1]. The authors are acknowledged for their contribution to a clinically significant question regarding the comparative outcomes of orbital atherectomy (OA) among diabetic and nondiabetic patients. Their findings offer valuable insights into the management of complex calcified lesions within a patient subgroup that has been relatively underexplored. Nevertheless, several methodological shortcomings remain that warrant further attention. First, the study does not provide quantitative imaging-based assessment. Without optical coherence tomography (OCT)/intravascular ultrasound (IVUS)-derived calcium scoring or plaque characterization, the depth and distribution of calcium within the lesion cannot be fully evaluated. Consequently, the effectiveness of atherectomy as well as the adequacy of stent expansion remain uncertain. This limitation reduces understanding of how the lesion was modified and how well the procedure was optimized. For instance, a study by Fujino et. al. showed that OCT-derived calcium scoring is a strong predictor of stent underexpansion and procedural results, highlighting the importance of intravascular imaging in assessing and confirming the effectiveness of atherectomy [2]. Second, the study did not take into consideration the use of antiplatelet or antidiabetic therapy which could significantly affect peri-procedural outcomes and restenosis risk, introducing unmeasured confounding. For instance, Angiolillo in his study demonstrated how the use of antiplatelet therapy in diabetic patients substantially impacts their risk of stent thrombosis and restenosis [3]. Another significant gap in the study is that it did not mention the complexity of lesion beyond calcification. It is vital to examine lesion complexity, given that particular traits, such as bifurcations or chronic total occlusions, are known to escalate procedural difficulties and impact outcomes, particularly among diabetic patients This relationship was clearly demonstrated by Serruys et. al. in the SYNTAX trial, which showed that lesion complexity strongly predicts both procedural success and long-term prognosis [4]. Lastly, the study did not conduct a sex specific analysis. This represents a significant limitation, as previous studies have indicated that women frequently exhibit smaller vessel sizes, more pronounced calcification, and increased procedural complications such as vessel dissection or perforation, all of which could affect the outcomes of OA. For instance, a recent multicenter study by Janish et. al. reported that women undergoing atherectomy experienced significantly higher rates of major adverse cardiovascular events (MACE) as compared to men. By not stratifying results by sex, this study may have missed clinically relevant procedural differences, even if overall outcomes appear similar. These findings emphasize the critical need for incorporating sex-stratified analyses in future OA studies to better comprehend and address potential procedural disparities [5]. In conclusion, the study provides valuable real-world evidence on the outcomes of OA in diabetic versus nondiabetic patients. However, several limitations such as the lack of quantitative imaging-based assessment, omission of adjunctive therapies, exclusion of lesion complexity, and the absence of sex-specific analyses restrict its depth and generalizability. Future studies should incorporate quantitative imaging assessment, medication profiling, lesion complexity scoring, and sex-based stratification to more accurately define the role of OA across diverse patient subgroups. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.