When “Leave–nothing–behind” Fails: Acute Thrombotic Vessel Occlusion After Dcb–only Pci in a Patient Requiring Ultra–short Dapt – A Case Report

Background Drug–coated balloon (DCB)–only percutaneous coronary intervention (PCI) represents a “leave–nothing–behind” strategy that may allow very–short dual antiplatelet therapy (DAPT), an appealing option in high–bleeding–risk patients requiring urgent non–cardiac surgery. However, acute vessel occlusion following DCB treatment of de–novo lesions remains an uncommon but potentially catastrophic complication. Case summary A 73–year–old man with prostate cancer awaiting urgent surgery underwent coronary evaluation, which revealed sub–occlusive stenoses of the mid–left anterior descending artery (LAD) and the proximal first obtuse marginal branch (OM1) (Figure 2). To minimize DAPT duration, a DCB–only strategy was selected. After lesion preparation with semi–compliant balloons, both vessels were treated with paclitaxel–coated balloons, achieving an apparently optimal angiographic result without visible dissection. Fifteen minutes after leaving the catheterization laboratory, the patient developed chest pain, hypotension, and anterolateral ST–segment elevation. Urgent repeat angiography demonstrated acute thrombotic occlusion of the LAD and sub–occlusion of OM1 at the treated segments (Figure 1). Bail–out drug–eluting stent implantation restored coronary flow with rapid clinical stabilization. Conclusion This case highlights that acute vessel occlusion may occur very early after DCB–only PCI despite angiographic success, particularly in complex de–novo lesions. Rigorous lesion preparation, careful patient and lesion selection, consideration of intracoronary imaging, and preparedness for immediate bail–out stenting are essential when adopting a stent–free strategy in patients requiring ultra–short DAPT.