Drug-Coated Balloons for Coronary Interventions: A Focused Review

Abstract

The development of catheter-based interventions has revolutionized the treatment of coronary artery disease (CAD), from the first heart catheterization in 1929 to the emergence of drug-coated balloons (DCBs) as a treatment for in-stent restenosis (ISR). This review explores the evolution and clinical application of DCBs in CAD, with a particular focus on their role in managing ISR, de novo coronary disease, and complex lesions. DCBs deliver antiproliferative drugs such as paclitaxel or sirolimus to the vessel wall and have emerged as a promising alternative to traditional stent-based therapies, reducing the need for permanent metallic implants and associated thrombotic risks. Early research demonstrated the effectiveness of DCBs in ISR, and recent studies have expanded their application to small vessel disease, bifurcation lesions, and long diffuse lesions. Notably, DCBs have shown non-inferiority to drug-eluting stents in certain cases, including high-risk patients and those with complex coronary anatomy. Despite some challenges, such as the potential for coronary dissection and the need for optimal lesion preparation, DCBs have demonstrated strong potential in reducing restenosis and improving long-term outcomes in a variety of patient populations. While further studies are required to refine their use in off-label indications, DCBs may represent a versatile, effective, and safer approach in the management of CAD.

Keywords: coronary artery disease; drug-coated balloon; in-stent restenosis; interventional cardiology; percutaneous coronary intervention.

Figure 1

Drug-coated balloon mechanism of action. Reproduced with permission from Boston Scientific.

Figure 2

Main characteristics and differences between paclitaxel and sirolimus drug-coated balloons. DCB: drug-coated balloon; PCB: paclitaxel-coated balloon; SCB: sirolimus-coated balloon; ISR: in-stent restenosis; MLD: mean lumen diameter

Figure 3

Coronary angiogram images demonstrating treatment of in-stent restenosis (ISR) using a drug-coated balloon (DCB). (A) Pre-treatment image showing 90% ISR in the affected artery. (B) Deployment of a 2.5 × 15 mm AGENT drug-coated balloon, inflated to 6 atm for 60 seconds. (C) Post-treatment image showing complete resolution of ISR with 0% stenosis after DCB intervention.

Figure 4

Drug-coated balloon coronary angioplasty indications.

Figure 5

Central illustration: Drug-coated balloon indication and treatment strategy in coronary artery disease. Adopted from the international DCB consensus group. DCB: drug-coated balloon; DES: drug-eluting stent; FFR: fractional flow reserve; ISR: in-stent restenosis; IVL: Intravascular lithotripsy; IVUS: intravascular ultrasound; NC: non-compliant; OCT: optical coherence tomography; OA: orbital atherectomy; PCI: percutaneous coronary intervention; RA: rotational atherectomy; SC: semi compliant

Figure 6

Coronary angiogram images illustrating treatment of de novo small vessel disease using a drug-coated balloon (DCB). (A) Pre-treatment image showing 90% stenosis proximal segment of the 1st diagonal branch. (B) Deployment of a 2.5 × 15 mm AGENT drug-coated balloon, inflated to 8 atm for 60 seconds. (C) Post-treatment image showing a significant reduction in stenosis to 20% following DCB intervention.

Figure 7

Coronary angiogram images demonstrating treatment of a de novo small vessel disease involving the ostial first diagonal branch with 90% stenosis using a drug-coated balloon (DCB). (A) Pre-treatment image showing 90% stenosis at the ostium of the first diagonal branch. (B) Deployment of a 2.5 × 12 mm AGENT DCB, inflated to 4 atm for 60 seconds. (C) Post-treatment image showing a reduction in stenosis to 30% and improved vessel patency following DCB intervention.