Clinical outcomes of drug-eluting stents versus drug-coated balloons in tortuous small coronary lesions

Abstract Background In recent years, drug-coated balloons (DCB) have emerged as an alternative to drug-eluting stents (DES), particularly in small vessel disease1. While both DES and DCB are commonly utilized in small vessels, the optimal treatment strategy for tortuous coronary lesions remains unclear. Due to their complex anatomy, tortuous lesions pose significant challenges in percutaneous coronary intervention (PCI), and comparative data on the long-term clinical outcomes of DES and DCB in this setting remain limited. Purpose This study aimed to evaluate and compare the 3-year clinical outcomes of DES and DCB in the treatment of small, tortuous coronary lesions. Methods This retrospective, single-center study included all consecutive patients who underwent PCI for small vessel tortuous lesions treated with either DES or DCB. Tortuous coronary lesions were defined as those with an angulation of ≥45° in at least one segment. Patients with chronic total occlusion, in-stent restenosis, or those receiving stents or balloons ≥3 mm were excluded. Procedural characteristics, including pre- and post-procedural angiographic parameters, were assessed. The primary endpoint was the incidence of major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, cardiac death, non-fatal myocardial infarction (MI), and target vessel revascularization (TVR) at 3 years. Results A total of 290 patients were included, with 85 treated with DCB and 205 with DES between February 8, 2016, and March 25, 2023. The mean age of the overall population was 71.2 ± 9.1 years, with a median follow-up of 565.4 ± 377.4 days. Baseline characteristics, including age, chronic kidney disease, and left ventricular ejection fraction, were similar between groups. Angiographic characteristics, including reference vessel diameter, minimum lumen diameter, and percentage diameter stenosis, were comparable; however, lesion length was significantly longer in the DES group compared to the DCB group (28.1 ± 13.9 mm vs. 22.2 ± 11.0 mm, p = 0.004). Regarding procedural data, pre-dilatation was significantly more frequent in the DCB group than in the DES group (p 0.01). At 3 years, there was no significant difference between the two groups in terms of all-cause mortality, cardiac death, or TVR. However, the incidence of MACE was significantly lower in the DES group compared to the DCB group (log-rank p = 0.023) (Figure 1). Conclusion Despite the lesion length being longer in the DES group, DES demonstrates superior outcomes compared to DCB in tortuous coronary lesions, particularly in reducing the incidence of MACE.Figure 1