Aggressive predilatation seeking medial dissection: a prerequisite for a drug-coated balloon-only strategy in de novo coronary lesions?

Drug-coated balloons (DCBs) are approved for the treatment of in-stent restenotic lesions, based on the results of several randomised controlled trials (RCTs)1. In clinical practice, operators balance the undeniable advantages of DCBs (predominantly the avoidance of an extra layer of metal in the coronary artery) against the moderately reduced antirestenotic efficacy as compared to repeat drug-eluting stent (DES) treatment2.

In recent years, the adoption of DCB technology in treating de novo coronary artery lesions has attracted important attention. The 'leave nothing behind’ concept is certainly appealing. Apart from the restoration of physiological vasomotion, long-term adverse events associated with stent implantation can also be avoided. Nevertheless, important questions remain with respect to safety in the short term (risk of subacute vessel closure) and efficacy in the long term. Data from small RCTs comparing DCBs with DES in de novo small coronary arteries have shown encouraging results34. When the vessel diameter is small, even moderate late lumen loss (LLL) after DES implantation can lead to an important reduction in the residual lumen area, leading to clinically relevant restenosis and...