Leave Nothing Behind in Coronary Intervention: Time to Move From Promise to Proof

We read with great interest the recent article by Meunier et al. [1] reporting the 3-year follow-up of a prospective all-comers observational study evaluating a stentless percutaneous coronary intervention (PCI) strategy with drug-coated balloons (DCB). The authors are to be commended for providing one of the most comprehensive long-term datasets on this approach. Their findings, particularly the low rate of target lesion revascularization (TLR) in the DCB-only cohort (2.6%) compared with the bailout drug-eluting stent (DES) group (6%), underscore the feasibility of a “leave nothing behind” strategy in contemporary practice. The rationale for DCB angioplasty rests on avoiding the long-term complications of permanent metallic scaffolds, including in-stent restenosis, neoatherosclerosis, and late thrombosis [2]. The durability of outcomes over 3 years in an unselected population provides important reassurance for interventional cardiologists considering wider adoption of a DCB-first approach. However, the absence of randomization precludes firm causal inference. The differences in TLR-free survival (p = 0.016) may reflect lesion complexity or operator selection bias rather than an actual treatment effect. Randomized controlled trials directly comparing stentless PCI with current-generation DES are required to establish durability, safety, and generalizability [3, 4]. Such studies should also examine endpoints beyond TLR, including myocardial infarction, late thrombosis, and patient-reported outcomes. Notably, the introduction of the “metal index” serves as a quantitative marker of stent burden. The observation that higher indices were associated with worse outcomes highlights their potential as a prognostic tool. Future research should validate the metal index in diverse cohorts and determine whether it can guide clinical decision-making, particularly when hybrid strategies necessitate bailout stenting. Patient and lesion selection also remain critical considerations. While small-vessel disease, bifurcations, and high-bleeding-risk subsets have been the traditional focus of DCB angioplasty [5], the favorable long-term outcomes reported here suggest that the potential scope of patients who may benefit could be broader. Rigorous comparative studies, including registry-based analyses, will be essential to delineate these populations more precisely. In summary, Meunier et al. provide compelling evidence that reinforces the biological and clinical appeal of a stentless PCI strategy, advancing the dialogue on the “leave nothing behind” paradigm. At the same time, their work should be viewed as a call to action: large-scale randomized trials are urgently needed to validate these observational insights, to explore the clinical utility of the metal index, and to define the optimal patient subsets for DCB-first strategies. Hasnain Wajeeh Saqib: writing – original manuscript. Talha Khan: writing – original manuscript. Rehman Bashir: writing – original manuscript. Tazeem Hayat: writing – original manuscript. Areesha Ishfaq Ahmed: writing – original manuscript. Ayesha Tariq: writing – original manuscript. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.