Drug-coated Balloon-only PCI for a Small-vessel Chronic Total Occlusion: A Stent-free Revascularization Strategy

Abstract

Drug-coated balloons provide local delivery of an antiproliferative agent to the coronary vessel wall without permanent metallic implantation and may offer a stent-free option in selected small-vessel lesions. Their use as stand-alone treatment for chronic total occlusion, however, remains less established. This case report describes a 70-year-old active smoker with a previous non-revascularised lateral ST-segment elevation myocardial infarction who was readmitted four months later with chest pain and acute left-sided heart failure. Coronary angiography demonstrated chronic total occlusions of the circumflex and left anterior descending arteries, and revascularisation of the circumflex artery was undertaken. After successful guidewire crossing, predilatation with a 2.5 × 15 mm non-compliant balloon at 15 atm resulted in approximately 30% residual stenosis, preserved distal flow, and no flow-limiting dissection. A drug-coated balloon-only strategy was therefore selected. Paclitaxel-coated balloons measuring 2.0 × 15 mm and 2.5 × 20 mm were applied to the distal and proximal circumflex artery, respectively, at 8 atm for 45 seconds. Final angiography demonstrated TIMI grade 3 flow without bailout stenting. Clinical follow-up was favourable, and repeat angiography at five months showed a sustained satisfactory result. The case supports the technical feasibility of drug-coated balloon-only revascularisation in a carefully selected small-vessel chronic total occlusion after satisfactory lesion preparation, while recognising the limited evidence available for this approach.