Very Late Chronic Total Occlusion After Drug-Coated Balloon Treatment for a Diffuse Long Coronary Lesion in Unstable Angina: A Case Report

A drug-coated balloon (DCB) strategy has become an established option for de novo coronary lesions, offering the advantage of avoiding permanent implants. However, very long-term vascular changes after stentless percutaneous coronary intervention (PCI) remain insufficiently characterized. We report a case of chronic total occlusion that developed eight years after DCB angioplasty for a diffuse long right coronary artery lesion in a patient with unstable angina. A 65-year-old man developed exertional chest discomfort approximately seven years after the index procedure, and cardiac computed tomography demonstrated severe calcification and suspected occlusion of the previously treated segment. At the index procedure, we selected a DCB-only strategy because intravascular ultrasound (IVUS) revealed a long, diffuse lesion requiring multiple stents and extensive drug-eluting stent (DES) implantation carries increased long-term risks. During repeat PCI, IVUS demonstrated dense calcification and high-echoic crescentic neointimal tissue without imaging features suggestive of thrombus. The imaging findings suggested atherosclerotic progression, potentially compounded by the limited acute luminal gain achieved at the index procedure, the cumulative burden of cardiovascular risk factors, and chronic inflammatory cell infiltration. Although the pharmacological effect of paclitaxel diminishes within months, preclinical studies have suggested that low residual tissue concentrations might contribute to late fibrotic or calcific remodeling. Device-related neoatherosclerosis appears unlikely because of the absence of a metallic scaffold. This case illustrates the multifactorial nature of very late vascular changes after stentless PCI and demonstrates how multimodality imaging, including cardiac computed tomography and IVUS, can describe late lesion morphology and healing patterns. The findings highlight the complex late-phase vascular morphology that may emerge in patients with diffuse disease and multiple risk factors and underscore the clinical value of comprehensive imaging assessment at very late follow-up.