Drug-Coated Balloon Angioplasty: A Novel Approach for the Revascularization of High-Bleeding Risk Patients

Bleeding is one of the most clinically significant complications after percutaneous coronary intervention (PCI) and markedly increases the risk of death. Almost half of contemporary patients undergoing PCI for chronic coronary syndrome or acute coronary syndrome have been reported to be at high bleeding risk (HBR) according to the Academic Research Consortium–High Bleeding Risk definition. Although modern drug-eluting stent PCI may allow for 1 month of dual antiplatelet therapy (DAPT) in patients at HBR, bleeding after drug-eluting stent implantation continues to be a significant clinical issue causing morbidity and mortality. In patients with chronic coronary syndrome, the current evidence supports 1-month DAPT after drug-coated balloon (DCB)-only PCI. Because DCB angioplasty leaves no permanent scaffold, it may provide greater flexibility for earlier DAPT de-escalation, single antiplatelet therapy, or antiplatelet treatment interruption in selected patients at HBR or after a bleeding event. Although registry trials suggest the potential of this approach, randomized clinical trials are essential to inform changes to current guidelines for the management of patients at HBR requiring coronary revascularization. This review outlines the clinical issue of bleeding following PCI, its prognostic implications, and the reasoning for using DCBs in this group of patients. It also discusses evidence supporting shorter antiplatelet therapy and highlights ongoing trials that are redefining the role of stentless PCI in managing patients at HBR in the catheterization lab.