Drug-Coated Balloon vs. Drug-Eluting Stents for De Novo Unprotected Left Main Stem Disease: The SPARTAN-LMS Study

A systematic review and meta-analysis of the use of drug-coated balloon angioplasty for treatment of both de novo and in-stent coronary chronic total occlusions

BACKGROUND

Modern contemporary percutaneous coronary intervention (PCI) techniques with drug-eluting stents (DES) have high procedural success rates in chronic total occlusion (CTO) but with a high prevalence of repeat revascularization. The use of drug-coated balloons (DCBs) in CTO is an alternative treatment strategy. The evidence for DCBs in CTO is, therefore, of interest, and we provide a structured and comprehensive review of the evidence available in terms of the use of DCBs in CTO, including de novo and in-stent (IS) CTO lesions.

OBJECTIVES

We conducted a systematic review and meta-analysis on the use of DCBs in the management of coronary CTO.

METHODS

Electronic databases (PubMed, Embase and Ovid) were systematically searched from inception to April 2024 for DCB CTO studies. A meta-analysis was undertaken using a random-effects inverse-variance method due to heterogeneity. The primary outcome is target lesion revascularization (TLR). Secondary outcomes are major adverse cardiac events (MACE) as a composite of target lesion revascularization (TLR), cardiac death (CD), and any myocardial infarction (MI) including procedural and non-procedural MI, target vessel revascularization (TVR), angiographic outcomes such as late lumen loss (LLL), binary restenosis, and reocclusion.

RESULTS

A total of 10 studies consisting of 1,695 patients were systematically reviewed. This showed that late luminal changes in terms of lumen gain and minimal lumen loss were consistently seen in CTO cohorts 7-12 months after DCB treatment. Five studies were included for meta-analysis with 1,474 patients. There were no significant differences in TLR between treatment strategies such as DCB, DES, and hybrid (DES + DCB) in both de novo and IS-CTO populations as follows: DCB vs DES [OR, 0.71; 95% CI 0.49-1.02], DCB vs DES in IS-CTO [OR, 0.78; 95% CI 0.45-1.34], DCB vs Hybrid [OR, 0.96; 95% CI 0.39-1.43], and hybrid vs DES [OR, 0.76; 95% CI 0.15-3.84]. Similar findings were seen with the MACE outcome. A sensitivity analysis showed no difference between the above-mentioned groups in terms of MI, CD, and TVR.

CONCLUSION

The limited initial evidence on DCB in coronary CTO-PCI suggests a safe and effective alternative treatment strategy and suggests RCTs are, therefore, required.

Efficacy and Safety of Sirolimus-Coated Balloon Angioplasty in De Novo Lesions in Large Coronary Vessels: A Propensity Score-Matched Study

BACKGROUND

Evidence regarding drug-coated balloon (DCB)-only angioplasty in de novo lesions of large vessels is still limited and mainly focused on paclitaxel-coated balloon. We aimed to analyze the safety and efficacy of sirolimus-coated balloon (SCB)-only angioplasty in de novo lesions in large vessels compared to drug-eluting stent (DES).

METHODS

In this retrospective, dual-center, case-control study, we enrolled all consecutive patients treated between January 2022 and January 2024 with SCB-only angioplasty in de novo lesion in large vessel (> 2.75 mm) compared to a propensity-score matched contemporary population treated with DES. The primary endpoint was the rate of target lesion revascularization (TLR), while secondary endpoints were cardiac death (CD), target vessel revascularization (TVR), myocardial infarction (MI), and target lesion failure (TLF), defined as a composite of them.

RESULTS

The mean age was 70.1 ± 9.8 years in the SCB group (n = 92) and 67.9 ± 9.6 years in the DES group (n = 92) (p = 0.76). The median follow-up was 19.5 ± 12 months in the SCB group and 20.1 ± 13.1 months in the DES group (p = 0.47). TLR occurred in 6.7% of patients in the SCB group and 5.6% in the DES group (p = 0.75). The incidence of MI, TVR, and TLF were similar between the two groups (4.3% vs 3.3%, p = 0.7, 2.2% vs 3.4%, p = 0.65% and 9.8% vs 8.7%, p = 0.79). CD occurred in 4.3% in the SCB group, compared to 3.3% in the DES group (p = 0.70).

CONCLUSION

Our study suggests that SCB angioplasty is both safe and effective in the treatment of de novo lesions of large vessels compared with DES.

Drug coated balloon angioplasty for de novo coronary lesions in large vessels: a systematic review and meta-analysis

We aimed to investigate the safety of drug-coated balloon (DCB)-only percutaneous coronary intervention compared to drug-eluting stent (DES) for de novo lesions in large vessels. To pursue this goal, we conducted a systematic review and meta-analysis following the PRISMA guidelines. The analysis included studies that utilized DCB-only or hybrid angioplasty for de novo lesions in large coronary vessel (> 2.75 mm). The primary outcome was to assess the target lesion revascularization (TLR) rate, while secondary outcomes included cardiac death, myocardial infarction (MI), and the composite of these. A total of 15 studies, comprising 3975 patients (of whom 2114 treated with DCB) were included. Median age was 62 ± 1.5 years, with 77.4% being male. Overall, 26.9% had diabetes, and 67.6% were diagnosed with acute coronary syndrome. Over a pooled follow-up of 20.6 ± 1.9 months, the incidence of TLR was 4% in the pooled DBC group. Additionally, over a pooled follow-up of 25.8 ± 2.7 months, no significant differences were observed in incidence of TLR between the DCB group and the DES group (4.3% vs. 6.9%, odds ratio 0.71, 95% confidence interval 0.50-1.01, p = 0.059). Furthermore, there were no differences in incidence of cardiac death and MI. DCB angioplasty treatment of de novo lesions in large coronary vessels could be a safe and effective strategy in both acute and chronic coronary settings. The incidence of target lesion revascularization appears to be similar to that of contemporary DES.

Long-Term Clinical Outcomes of Drug-Coated Balloon Following Directional Coronary Atherectomy for Bifurcated or Ostial Lesions in the DCA/DCB Registry

BACKGROUND

The long-term efficacy of drug-coated balloon (DCB) angioplasty for large bifurcation lesions, particularly those involving the left main trunk (LMT), remains unclear.

AIMS

This study aimed to evaluate the long-term outcomes of directional coronary atherectomy followed by DCB (DCA/DCB) for large bifurcation lesions.

METHODS

This retrospective multicenter study analyzed 129 cases from the DCA/DCB registry, with 80.4% involving LMT bifurcation lesions. Building on previously reported 12-month outcomes, this study assessed long-term results. The primary endpoint was clinically driven (CD) target lesion revascularization (TLR) at 36 months. Secondary endpoints included CD target vessel revascularization (TVR); CD target vessel failure (TVF); and adverse events, such as all-cause mortality, cardiac death, target vessel acute myocardial infarction (AMI), and the need for coronary artery bypass grafting (CABG), at 24 and 36 months.

RESULTS

The mean follow-up was 53.4 ± 23.9 months. The CD-TLR rate was 5.0% at 24 months, and the primary endpoint was 5.9% at 36 months. CD-TVR rates were 14.0% at 24 months and 15.0% at 36 months, while CD-TVF rates were 14.9% at 24 months and 16.7% at 36 months. Adverse events included all-cause mortality rates of 0.8% at 24 months and 1.8% at 36 months, and cardiac death rates of 0.8% at both 24 and 36 months. No target vessel AMI or CABG procedures were reported.

CONCLUSION

The consistently low CD-TLR rate at 36 months supports the efficacy of the DCA/DCB strategy for large bifurcation lesions, including LMT, indicating its sustained effectiveness. These findings highlight the viability of this treatment approach.

Comparison of Efficacy and Safety Between Drug-Coated Balloons Versus Drug-Eluting Stents in the Treatment of De Novo Coronary Lesions in Large Vessels: A Study-Level Meta-Analysis of Randomized Control Trials

BACKGROUND

Drug-coated balloons (DCB) can be used as an alternative to drug-eluting stents (DES) in patients with de novo small vessel coronary artery disease. This study aims to assess the efficacy and safety of solely using DCB versus DES in percutaneous coronary intervention (PCI) for de novo coronary lesions in large vessels.

METHOD

A database search was conducted using PubMed, EMBASE, Cochrane Library, and http://Clinicaltrials.gov for trials comparing DCB only with DES in treating de novo coronary lesions in large vessels. Efficacy outcomes included coronary angiography (CAG), follow-up minimal lumen diameter (MLD), and late luminal loss (LLL). Safety outcomes included target lesion failure [TLF: cardiac death, myocardial infarction (MI), target lesion revascularization (TLR)] and their individual components.

RESULTS

We included seven randomized control trials (RCTs) with 816 patients, of which 422 and 394 patients were in the DCB and DES groups, respectively. MLD measured during the 6-12 months follow-up in the DCB group was statistically significantly smaller than in the DES group (MD -0.21, 95% CI -0.34 to -0.07, P = 0.003, I2 = 52%). LLL measured at 6-12 months follow-up was statistically significantly lower in the DCB group than in the DES group (MD -0.13, 95% CI -0.22 to -0.05, P = 0.003, I2 = 60%). TLF, cardiac death, MI, and TLR, were not statistically significantly different between the two groups.

CONCLUSION

Use of DCB was associated with less LLL at 6-12 months than DES and was not associated with any increase in adverse clinical events. This data suggests DCB are as effective in treating de novo coronary lesions in large vessels as DES.

One-Month Duration Compared with Twelve-Month Duration of Dual Antiplatelet Therapy in Elective Angioplasty for Coronary Artery Disease: Bleeding and Ischaemic Outcomes

Background/Objectives: The need to determine the safest duration of dual antiplatelet therapy duration after elective angioplasty to reduce bleeding events without an adverse effect on major adverse cardiovascular events (MACE) remains a challenge. Methods: In this investigator-initiated, single-centre cohort study, we identified all patients who underwent PCI for de novo coronary disease for stable angina between January 2015 and November 2019. We compared 1-month and 12-month durations of dual antiplatelet therapy (DAPT) to determine if there was any difference in the primary outcome of major bleeding. The secondary outcome was a patient-oriented composite endpoint of all-cause mortality; any myocardial infarction, stroke, or revascularisation; and the individual components of this composite endpoint. Data were analysed using Cox regression models and cumulative hazard plots. Results: A total of 1025 patients were analysed, of which 340 received 1 month of DAPT and 685 received 12 months of DAPT. There was no difference in major bleeding between the two groups (2.6% vs. 2.5% respectively). On univariable cox regression analysis, no characteristics were predictors of major bleeding. A proportion of 99.7% of patients in the 1-month DAPT arm were treated with a DCB strategy, whilst 93% in the 12-month DAPT group were treated with a DES. There was no difference between the two groups with regards to the composite patient-oriented MACE (11% vs. 12%, respectively) or any individual component of this. These results were unchanged after propensity score matched analysis. Conclusions: A 1-month duration of DAPT, for which 99.7% of patients were treated with a DCB strategy, appears safe and effective when compared with a 12-month duration of DAPT with no difference in major bleeding or MACE.

Drug-coated balloon versus drug-eluting stent for treating de novo large vessel coronary artery disease: a systematic review and meta-analysis of 13 studies involving 2888 patients

INTRODUCTION

Drug-coated balloon (DCB) is an established treatment option for in-stent restenosis and small vessel, de novo, coronary artery disease (CAD). Although the use of this tool is increasing in everyday practice, data regarding performance in the treatment of de novo, large vessel CAD (LV-CAD) is still lacking. A systematic review and meta-analysis were conducted to evaluate the efficacy and safety of DCB versus drug-eluting stent (DES) in this setting.

METHODS

A comprehensive literature search was performed including Medline, Embase, and Cochrane electronic databases up to January 24, 2024, for studies which compared the efficacy and safety of DCB versus DES in the treatment of de novo lesions in large vessels (≥ 2.5 mm), reporting at least one clinical outcome of interest (PROSPERO ID: CRD42023470417). The analyzed outcomes were cardiovascular death (CVD), myocardial infarction (MI), target lesion revascularization (TLR), all-cause death (ACD), and late lumen loss (LLL) at follow-up. The effect size was estimated using a random effects model as risk ratio (RR) and mean difference (MD) and relative 95% confidence interval (CI).

RESULTS

A total of 13 studies (6 randomized controlled trials and 7 observational studies) involving 2888 patients (DCB n = 1334; DES n = 1533) with de novo LV-CAD were included in this meta-analysis following our inclusion criteria. No differences were observed between DCB and DES in terms of CVD (RR 0.49; 95% CI [0.23-1.03]; p = 0.06), MI (RR 0.48; 95% CI [0.16-1.45]; p = 0.89), TLR (RR 0.73; 95% CI [0.40-1.34]; p = 0.32), ACD (RR 0.78; 95% CI [0.57-1.07]; p = 0.12), and LLL (MD - 0.14; 95% CI [- 0.30 to 0.02]; p = 0.10) at follow-up. DES proved a higher mean acute gain versus DCB [1.94 (1.73, 2.14) vs 1.31 (1.02, 1.60); p = 0.0006].

CONCLUSION

Our meta-analysis showed that DCB PCI might provide a promising option for the management of selected, de novo LV-CAD compared to DES. However, more focused RCTs are needed to further prove the benefits of a "metal-free" strategy in this subset of CAD.

Factors influencing coronary artery target lesion revascularization after drug-coated balloon angioplasty

Background

Concerns regarding restenosis after treatment with drug-coated balloons (DCB) remain. We aimed to identify the incidence of target lesion revascularization (TLR) and explore clinical, procedural, and other factors influencing it.

Methods

Single-center retrospective analysis of a prospective cohort PCI registry study included 80 patients (100 lesions) who underwent successful DCB angioplasty between January 2020 and October 2023 and follow-up angiography within 2 years of either planned or unplanned reason. Incidence and factors associated with TLR were analyzed.

Results

Angiographic evaluation was conducted within a median of 151 days (interquartile range: 109 days). During index procedure, 54% were complex lesions. Intravascular imaging (IVI) was performed in 80% of lesions. TLR occurred in 11% of the lesions and was less frequent in the IVI group compared to the angiography-alone group [6.3 vs. 54.5%; odds ratio: 0.156, 95% confidence interval (CI): 0.042-0.580; p = 0.002]. No association was found between baseline and lesion characteristics, lesion complexity, plaque morphology, pre-dilatation procedure balloon type, maximal inflation pressure, or length of DCB between the groups (p > 0.05). Multivariate analysis revealed that IVI utilization was independently associated with a lower TLR rate (adjusted odds ratio: 0.116, 95% CI: 0.020-0.669; p = 0.016).

Conclusion

In DCB angioplasty, only IVI use exhibited a significant difference in the TLR rate among baseline lesion characteristics and lesion preparation and was independently associated with a lower TLR rate.

A New Frontier for Drug-Coated Balloons: Treatment of "De Novo" Stenosis in Large Vessel Coronary Artery Disease

Background: Drug-coated balloons (DCB) are a well-established option for treating in-stent restenosis endorsed by European Guidelines on myocardial revascularization. However, in recent years, a strategy of "leaving nothing behind" with DCB in de novo coronary stenosis has emerged as an appealing approach. Methods: We performed a systematic review to evaluate the current literature on the use of drug-coated balloons in the treatment of de novo stenosis in large vessel disease. Results: Observational studies, as well as randomized studies, demonstrated the safety of DCB percutaneous coronary interventions (PCI) in large vessel disease. The rate of major adverse cardiac events is even lower compared to drug-eluting stents in stable coronary artery disease. Conclusions: DCB PCI is feasible in large vessel disease, and future large, randomized studies are ongoing to confirm these results.

Stent, balloon and hybrid in de novo PCI: could the whole be greater than the sum of its parts?

Andreas Grüntzig, an ardent angiologist crafted an indeflatable sausage-shaped dual-lumen balloon- catheter, designed its delivery to the heart, launched minimally invasive coronary intervention and taught by beaming live demonstration. Subsequent advances are just incremental tweaks and tinkers around this fully formed framework from 1978. The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug- eluting stent, drug-coated balloon, or both in different combinations and permutations. Now with Grüntzig's balloon armed with an antiproliferative drug, it could dominate the field once more, as he originally envisaged.

Cost effectiveness analysis of drug coated balloon only angioplasty for de novo coronary artery disease

AIMS

We aimed to perform a cost analysis of drug coated balloon (DCB)-only angioplasty versus drug eluting stent (DES), for de novo disease of all vessel sizes and all clinical indications.

BACKGROUND

DCB angioplasty is an emergent technology for the treatment of coronary artery disease. There is lack of data regarding the cost-effectiveness of DCB-only angioplasty for treatment of de novo coronary artery disease as compared with second generation DES.

METHODS

We compared total costs of patients treated with DCB or DES for first presentation of ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or stable angina due to de novo disease between January 1, 2018 and November 15, 2019. We defined total cost as the sum of (1) procedural devices-cost, (2) procedural staff-cost, (3) post-percutaneous coronary intervention hospital stay cost, and (4) antiplatelet regime cost. A cost minimization analysis was performed to compare the costs of DCB and DES.

RESULTS

We present 1952 all-comer, consecutive patients; 902 (1064 lesions) treated with DCB and 1050 (1236 lesions) treated with DES for de novo coronary artery disease. The cost per patient was estimated to be £9.02 more expensive in the DCB group (£3153.00 vs. £3143.98). However, the cost per lesion treated was calculated to be £15.51 cheaper in the DCB group (£3007.56 vs. £3023.07). The results were consistent irrespective of duration of long-term antiplatelet medications.

CONCLUSION

We have compared the cost-effectiveness of DCB-only angioplasty to DES-angioplasty and showed that the per patient and per lesion results were not different and hence cost should not be implicated in the decision to choose DCB or DES.