Drug-Coated Balloons-Based Intervention for Coronary Artery Disease: The Second Report of Asia-Pacific Consensus Group

Abstract

Drug-coated balloons (DCBs) provide a stent-free alternative, reducing risks like stent thrombosis and in-stent restenosis and the need for prolonged dual antiplatelet therapy. Recent studies show that DCBs can be effective and safe across various coronary artery diseases (CADs) when lesions are adequately prepared. Specifically, all coronary lesions are treated using the provisional approach, where active lesion preparation is followed by DCB or drug-eluting stent treatment, depending on the results. This approach means DCB is considered the default device before initiating intervention, with efforts focused on obtaining adequate lesion preparation. Depending on the result, DCB or drug-eluting stent is selected, which is termed DCB-based percutaneous coronary intervention. Therefore, this second report of the Asia-Pacific Consensus Group provides practical guidelines (DCB-based percutaneous coronary intervention) based on the latest evidence for DCB treatment in CAD and aims to expand its application across various CADs, facilitating its effective use in real-world clinical practice.

Keywords: balloon angioplasty; coronary artery disease; drug-eluting stent; percutaneous coronary intervention.

Graphical abstract

Central Illustration

Drug-Coated Balloon–Based Treatment Approach for Coronary Artery Disease Drug-coated balloon (DCB)–based percutaneous coronary intervention prioritizes optimal lesion preparation, using DCB as the default device and deciding between DCB or drug-eluting stent (DES) based on outcomes. This approach minimized stent use, ensuring effective drug delivery and reducing the need for bailout stenting. FFR = fractional flow reserve.

Figure 1

DCB Treatment Approach for True Bifurcation Lesion The procedure involves predilating vessels with a balloon-to-vessel ratio of 0.9 to 1.0 and applying drug-coated balloon (DCB) if flow-limiting dissection is absent and residual stenosis meets criteria in main vessel and/or side-branch. DCB should cover the predilated area with appropriate overlap, but if results are unsatisfactory, drug-eluting stent (DES) implantation in the main vessel and/or side-branch may be considered. MV = main vessel; SB = side branch.

Figure 2

DCB Treatment Approach for Chronic Total Occlusion Lesion The DCB-based strategy effectively treats CTO lesions with adequate preparation and TIMI flow grade 3 and the residual diameter stenosis ≤50%, but DES is preferred if a subintimal approach is used, even if criteria are met. Abbreviations as in Figure 1.

Figure 3

DCB Treatment Approach for Acute Myocardial Infarction In acute myocardial infarction patients, the use of intravascular imaging can assist in the detection and confirmation of thrombus presence. Predilation with a 1.0 balloon-to-vessel ratio is required, followed by DCB treatment if the residual stenosis is ≤30% without flow-limiting dissection and the thrombus burden is low. If lesion preparation is inadequate or a high thrombus burden persists, DES implantation is employed as a provisional strategy. Abbreviations as in Figure 1.