A case report of late vessel occlusion presenting as ST-segment elevation myocardial infarction after drug-coating balloon treatment of in-stent restenosis

Background: Drug-coated balloons (DCBs) offer an appealing therapeutic alternative for the treatment of patients with coronary in-stent restenosis (ISR). In-segment late lumen loss, translating into recurrent ISR and the clinical need for target lesion revascularization, represents a well-established and thoroughly investigated limitation of DCB in this setting. However, abrupt vessel occlusion, clinically presenting as ST-segment elevation myocardial infarction (STEMI), has not been previously described after DCB therapy for ISR. Case summary: We herein present the case of a 70-year-old patient that underwent percutaneous coronary intervention (PCI) with DCB for ISR. Despite achieving an excellent acute angiographic result (with no flow-limiting dissection and minimal angiographic residual stenosis), the patient presented 3 months later with STEMI due to occlusion of the previously treated segment. After adequate lesion preparation, a drug-eluting stent was implanted with optimal final angiographic result. The patient was discharged 2 days after the PCI without any post-procedural complications and remained asymptomatic at 6-month clinical follow-up. Discussion: This case report is the first description of an abrupt vessel occlusion presenting as STEMI following a DCB angioplasty for ISR. This exceptional presentation does not dismount the solid evidence supporting the long-term safety of DCB in these challenging patients.