Drug-coated Balloon in Coronary Artery Disease

Drug-coated balloons (DCBs) have emerged as a novel treatment modality designed to deliver an antiproliferative drug directly to the vessel wall during balloon inflation while leaving no permanent implant behind.The "leave nothing behind" concept is particularly attractive in reducing long-term risks associated with metallic scaffolds and potentially enabling shorter DAPT duration.The clinical utility of DCBs was first demonstrated in the management of in-stent restenosis (ISR), where randomized trials and meta-analyses consistently confirmed their superiority over plain balloon angioplasty and noninferiority compared with certain DES.Subsequently, the role of DCBs has expanded to include de novo small-vessel disease, bifurcations, and more recently, larger vessels and acute coronary syndromes.Parallel advances in coating technologies, excipients, and the development of sirolimus-based DCBs have further broadened their clinical applicability.Recent randomized trials, long-term follow-up data, and pooled meta-analyses have reinforced the safety and efficacy of DCBs in selected patient and lesion subsets.In this review, we IntroductIonCoronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide despite major advances in prevention, diagnosis, and revascularization strategies.Andreas Gruntzig first treated coronary stenosis using a balloon and kickstarted the era of coronary interventions.Percutaneous coronary intervention (PCI) has evolved dramatically since then, progressing from plain old balloon angioplasty (POBA) to baremetal stents (BMS), and subsequently to drug-eluting stents (DES).While contemporary DES have significantly reduced rates of restenosis and target lesion revascularization (TLR) compared with plain balloon angioplasty and BMS, several limitations persist.These include the permanent implantation of a metallic scaffold, risk of late stent thrombosis, neoatherosclerosis, and the requirement for prolonged dual antiplatelet therapy (DAPT) in certain patient populations.Clinical evidence indicates that DES are linked to late adverse events and neoatherosclerosis, with very late ischemic complications occurring in roughly 2% of patients per year and ischemia-driven TLR reported in 4.4% of cases during 1-5 years of follow-up and attributed to caging of arteries by metallic implants.Multiple factors such as loss of vasomotion, change in flow characteristics of the vessel, late loss, metal crowding in bifurcations, and overlapping stents led to metal-less PCI.Leaving permanent metallic scaffolds may not be an optimal strategy, especially in complex lesions, and could limit future treatment strategies.To overcome the drawbacks of permanent metallic implants, bioresorbable vascular scaffolds (BVS) were developed with the aim of providing temporary vessel scaffolding, drug delivery, and eventual resorption to restore native vascular physiology.Early-generation scaffolds, most notably the Absorb BVS, showed promise in concept but were limited by issues of strut thickness, scaffold thrombosis, and inferior outcomes compared with newergeneration DES in randomized trials.