Outcomes of drug-coated balloon, crossover stenting, and ostium stenting for LAD lesions with ostial plaque continuity: an IVUS-guided comparative study

Background In percutaneous coronary intervention (PCI) for proximal left anterior descending artery (LAD) lesions with plaque continuity to the ostium, the optimal revascularization strategy remains controversial. Previous studies have suggested that left main (LM)–to–LAD crossover stenting may reduce repeat revascularization compared with focal ostial stenting1, although acceptable outcomes have also been reported with ostium-only stenting when lesion coverage is appropriate. With the increasing use of drug-coated balloons (DCBs) under intravascular imaging guidance, whether outcomes differ according to the final treatment strategy remains unclear2. Methods Between April 2023 and March 2025, 146 consecutive patients undergoing PCI for LAD lesions with angiographically and intravascular ultrasound (IVUS)-confirmed ostial plaque continuity were retrospectively analyzed. Patients were classified into three groups according to the final strategy: DCB-only (n=28), crossover stenting from the left main trunk (n=65), and ostium stenting (n=53). LAD ostial plaque burden was assessed by IVUS as percentage plaque area (plaque area/vessel area). Clinical endpoints included major adverse cardiac events (MACE: target lesion revascularization [TLR], cardiac death, or myocardial infarction) and target vessel revascularization (TVR). Results Crossover stenting was more frequently selected in lesions extending from the left main trunk (p=0.011), whereas debulking devices were more commonly used in the DCB group (p<0.001). Baseline and post-preparation plaque burden differed among groups (DCB vs. crossover vs. ostium stenting: 42.7±19.6% vs. 53.4±17.8% vs. 44.2±15.7%; p=0.026), with the highest burden observed in the crossover stent group. However, at final IVUS assessment, plaque burden became significantly smaller in the crossover stent group (p=0.048). Kaplan–Meier analysis demonstrated no significant differences among the three strategies in MACE (p=0.24), TLR (p=0.25), or TVR (p=0.97). Among 13 patients in the ostium stenting group with residual uncovered plaque, additional DCB angioplasty did not affect clinical outcomes. Conclusion When lesion attachment and plaque burden are appropriately assessed, finalization with DCB or ostium stenting achieves clinical outcomes comparable to crossover stenting for LAD lesions extending to the ostium, without compromising mid-term results.