Small-Vessel Coronary Disease and Drug-Coated Balloons: Time to Reconsider Our Strategy?

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has dramatically transformed coronary revascularization, reducing restenosis and the need for repeat interventions. Nevertheless, despite major advances in stent bioengineering and procedural techniques, the permanent implantation of metallic platforms and polymer coatings remains associated with long-term stent failure, particularly in small coronary arteries, with an annual incidence of stent thrombosis of approximately 1–2%. The underlying mechanisms include neointimal hyperplasia, neoatherosclerosis, stent fracture, and the inability to achieve positive remodeling, all resulting from the “caging” of vessels with metallic struts. Against this background, the use of drug-coated balloons (DCBs) for the treatment of de novo lesions—embodying the “leave nothing behind” strategy—has emerged as an attractive alternative to overcome limitations inherent to stent implantation.

In recent years, an increasing number of trials have underscored the clinical relevance of DCB angioplasty for de novo lesions. The avoidance of permanent device implantation into the vessel wall is particularly appealing. On the other hand, a key objective of PCI is to achieve acute luminal gain while minimizing dissections and impaired flow—an aspect where stents retain a clear advantage. Still, PCI with DES in small arteries has consistently been associated with higher rates of target lesion failure. In this context, a DCB-based angioplasty is compelling. Recent evidence has suggested comparable outcomes between DCBs and DES in small-vessel disease; however, non-inferiority designs and small sample sizes have limited these findings.

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