Acute coronary syndrome vs chronic coronary syndrome drug-eluting balloon PCI: a lesion-level analysis of predictors and outcomes of target lesion failure

Background Drug-eluting balloon (DEB) angioplasty is increasingly used across the spectrum of chronic coronary syndromes (CCS) and acute coronary syndromes (ACS), but comparative lesion-level data for ACS versus CCS procedures are limited. Methods We conducted a retrospective single-centre analysis of 398 consecutive patients (mean age 67.1±12.6 years, 83.2% male) treated with DEB, yielding 518 DEB-treated lesions. Hypertension, dyslipidaemia and diabetes were present in 77.4%, 78.4% and 38.2% of patients, respectively. Baseline presentation was STEMI in 21.4%, NSTEMI 29.1%, unstable angina 4.3% and chronic coronary syndrome 45.0%. ACS (STEMI/NSTEMI/UA for 271 lesions (52.3%), whereas 247 lesions (47.7%) were CCS. Lesion complexity was frequent (bifurcation 40.9%, de novo 75.5%, in-stent restenosis 24.9%). The primary endpoint was lesion-level TLF (composite of TLR and non-TLR events including MI/CV death); secondary endpoints were TLR and TLF components. Univariate comparisons (Fisher’s exact test) and penalised multivariable logistic regression were performed. Results Over follow-up, TLF occurred in 12/271 ACS lesions (4.43%) versus 2/247 CCS lesions (0.81%; odds ratio [OR] 5.68, p=0.013). In contrast, TLR rates were low and similar (0.74% ACS vs 0.81% CCS, OR 0.91, p=1.000). Subanalysis of TLF components and secondary outcomes showed increased cardiovascular death (2.95% vs 0.81%, p=0.110) and all-cause death (4.43% vs 2.04%, p=0.146), while follow-up MI rates were comparable (2.58% vs 2.02%, p=0.775), as well as numerically higher non-TLR events in ACS lesions (18.1% vs 12.6%, p=0.089). In multivariable analysis, ACS presentation remained an independent predictor of TLF (adjusted OR 6.15, 95% CI 1.66–22.82; p=0.007), and bifurcation lesions were also associated with higher TLF risk (adjusted OR 4.48, 95% CI 1.30–15.44; p=0.018); other lesion characteristics, AHA class and segment location were not significant. Conclusion In this analysis, ACS presentation was independently associated with a six-fold higher risk of target lesion failure after DEB PCI compared with CCS, driven predominantly by cardiac death and target-vessel MI rather than repeat revascularisation. Importantly, TLR rates remained very low and comparable between ACS and CCS lesions, suggesting preserved local anti-restenotic efficacy of the DEB platform. This pattern contrasts with contemporary drug-eluting stent (DES) data, where excess adverse events in ACS are typically driven by both thrombotic complications and restenosis-related TLR. The absence of increased TLR in ACS lesions suggests that biological instability of ACS—rather than insufficient antiproliferative effect—may account for the higher event rates. These findings highlight that, similar to DES in ACS, overall outcomes remain influenced by clinical presentation; however, DEBs appear to maintain local lesion control comparable to CCS when adequate lesion preparation is achieved.