Expanding the role of drug-coated balloons in native large coronary artery disease

We have witnessed a remarkable evolution in the field of percutaneous coronary intervention (PCI) over the past half a century, transitioning from the first cases of balloon angioplasty to bare metal stents and, most notably, to the widespread use of drug-eluting stents (DES). The advent of DES substantially reduced restenosis rates by providing a mechanical scaffold combined with sustained release of an antiproliferative drug, eg, taxanes and then rapamycin derivatives. Considering their permanent and static nature, such metallic implants are not without limitations, including the potential for delayed healing, chronic inflammation, inhibition of positive vessel remodeling, and the need for prolonged antithrombotic therapy.1,2 Following this, the concept of bioresorbable vascular scaffolds emerged, promising a temporary scaffold that would “leave nothing behind”. Nonetheless, their initial promise was hampered by late scaffold thrombosis and a high rate of target lesion failure.3 At the same time, drug-coated balloons (DCB) emerged as a “metal-free” alternative delivering an antiproliferative drug to the vessel wall without leaving a permanent implant, thus preserving vessel anatomy, function, and allowing for adaptive remodeling. Currently, DCB are established in percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) and, subsequently, for small-vessel native disease. Their role in larger native coronary arteries,...