Drug-coated balloon versus drug-eluting stent after atherectomy in severely calcified coronary lesions including calcified nodules

Background Severely calcified coronary lesions often require plaque modification using atherectomy devices such as Rotablator™ or Diamondback®. However, even after adequate lesion preparation, stent underexpansion may occur. In such situations, particularly in lesions with calcified nodules, a stentless strategy using a drug-coated balloon (DCB) has recently been adopted. Nevertheless, the clinical outcomes of this approach remain unclear. Purpose We aimed to compare the clinical outcomes of DCB versus drug-eluting stent (DES) following atherectomy in severely calcified coronary lesions, further stratified into calcified sheet and calcified nodule based on intravascular imaging findings. Methods All consecutive severely calcified lesions requiring atherectomy at our institution between 2017 and 2023 were retrospectively analyzed. Atherectomy devices included Rotablator™ and Diamondback®. The choice of final device (DCB or DES) was left to the operator’s discretion. Lesions were evaluated using intravascular ultrasound (IVUS) or optical frequency domain imaging (OFDI) and categorized as calcified sheet or calcified nodule. The primary endpoint was device-oriented cardiovascular events (DoCE), defined as ischemia-driven target lesion revascularization, myocardial infarction, or cardiac death. DoCE rates were compared between DCB and DES groups overall and within each calcification subtype. Results A total of 148 lesions were included as shown in figure 1 (DCB: n=56; DES: n=92). Baseline characteristics were comparable between groups (table). A representative case is shown in figure 2. Overall, DoCE rates were not significantly different between DCB and DES in severely calcified lesions (Figure 3A, P=0.14). When stratified by lesion morphology, DoCE rates were comparable between the two strategies in calcified sheet lesions (Figure 3 B, P=0.98). In contrast, in calcified nodules, DCB showed a trend toward lower DoCE compared with DES (Figure 3C, P=0.07). Conclusion A stentless strategy using DCB after atherectomy may be a feasible alternative to DES, particularly in lesions with calcified nodules.