Practical Tips and Strategic Approaches for Drug-Coated Balloon-Based Percutaneous Coronary Intervention: Beyond the “Drug-Coated Balloon vs. Drug-Eluting Stent” Debate

Coronary drug-coated balloon (DCB) treatment has become an important option in contemporary percutaneous coronary intervention (PCI), particularly for in-stent restenosis and small-vessel disease.However, clinical outcomes after DCB treatment remain heterogeneous across clinical studies and real-world practice, largely because of variability in lesion preparation, procedural endpoints, and intraprocedural decision-making.Unlike stent-based PCI, in which procedural success is primarily determined by device implantation and structural optimization guided by angiography and intravascular imaging, DCB-based PCI depends on adequate lesion preparation and effective drug delivery without permanent scaffolding.In this review, we move beyond the conventional "DCB vs. drug-eluting stent" paradigm and present a practical, procedure-oriented framework for DCB-based PCI.We emphasize lesion preparation adequacy, rather than device selection, as the central determinant of treatment strategy.Optimal lesion preparation is defined by acceptable residual stenosis, preserved coronary flow, and the absence of flow-limiting dissection, marking a shift from angiographic perfection toward procedural conditions that support effective drug transfer and vessel healing.Building on this concept, we describe a structured decision-making approach in which inadequate lesion preparation prompts consideration of either iterative lesion modification, referred to here as a retry strategy, or transition to stent implantation, referred to here as an exit strategy.This framework integrates lesion preparation techniques, procedural endpoints, and real-time decision-making into a cohesive strategy tailored to DCB-based PCI.By focusing on procedural logic rather than device comparison, this review offers practical guidance for interventional cardiologists and outlines a clinically relevant approach to improving outcomes in DCB-based PCI.