LEAVING NOTHING BEHIND: DRUG-COATED BALLOON ANGIOPLASTY FOR DISTAL LEFT MAIN BIFURCATION IN-STENT RESTENOSIS AND NATIVE LCX OSTIUM LESION – CASE SERIES

Background: In-stent restenosis (ISR) in bifurcation lesions, particularly involving the ostial left circumflex (LCX)– Highobtuse marginal (OM) artery, remains a major therapeutic challenge. Repeat drug-eluting stent (DES) implantation increasesmetal burden and may adversely affect long-term vascular healing. Drug-coated balloons (DCB) offer a “leave nothingbehind” strategy that may be particularly advantageous in this setting, especially in LCX ostial ISR within distal left main(LM) bifurcation anatomy. Case summary: We report five cases of complex coronary artery disease with recurrent ISRinvolving the LCX–OM bifurcation. Notably, these represent LCX ostial ISR in the setting of distal LM bifurcation disease,often following prior LM–LAD stenting, with associated high OM1 involvement, further increasing procedural complexity.Three patients underwent successful DEB angioplasty to LCX Ostial ISR following meticulous lesion preparation, achievingoptimal angiographic results without complications or need for additional stenting. The Two case illustrates successfulDEB angioplasty to the native LCX ostium and high OM with critical lesions, achieving an excellent angiographic result.Conclusion: DCB angioplasty demonstrated excellent procedural success in complex bifurcation ISR, preserving vesselarchitecture and avoiding further metal layering. These findings align with contemporary evidence supporting DCB as apreferred strategy in ISR, particularly in bifurcation lesions and emerging applications in distal LM bifurcation subsets.