Drug-coated balloon-first versus drug-eluting stent strategy for de novo diffuse left anterior descending disease: a propensity-weighted cohort
F Khan, D R Fazal Akbar, D R Kamran Aslam, D R Muhammad WaleedAbstract
Background
Diffuse left anterior descending coronary disease often forces long, overlapping stent segments. That solves acute scaffolding but leaves a large permanent metal footprint, which can translate into repeat revascularisation in real-world follow-up. A drug-coated balloon-first approach aims to deliver antiproliferative therapy without an implant, but the practical concern is whether balloon-only treatment can achieve a reliable final result in long lesions and whether any short-term advantage persists beyond the procedure.
Purpose
To compare a drug-coated balloon-first strategy (bail-out stenting permitted) with a drug-eluting stent strategy for procedural success and 12-month clinical outcomes in de novo diffuse left anterior descending disease.
Methods
We analysed consecutive adults undergoing percutaneous coronary intervention between January 2023 and December 2024 for de novo left anterior descending lesions with angiographic length ≥20 mm. In-stent restenosis and planned hybrid index strategies were excluded to keep treatment attribution clear. Because operators tend to select drug-coated balloons for different anatomy than stents, we chose inverse probability of treatment weighting to reduce confounding while preserving the full cohort, and we checked overlap and balance after weighting. Time-to-event outcomes were assessed using Kaplan–Meier methods and Cox regression; a prespecified strategy-based sensitivity analysis retained bail-out conversions within the attempted drug-coated balloon group.
Results
Among 520 patients, 262 underwent a drug-coated balloon-first strategy and 258 underwent a drug-eluting stent strategy. Lesion complexity was higher in the drug-coated balloon group (type C: 181/262 [69.1%] vs 145/258 [56.2%]). Procedural success was similar (255/262 [97.3%] vs 248/258 [96.1%]). At 12 months, major adverse cardiovascular events occurred less often with the drug-coated balloon strategy (28/262 [10.7%] vs 43/258 [16.7%]), driven by fewer target lesion revascularisations (12/262 [4.6%] vs 27/258 [10.5%]). Event-free survival was higher with drug-coated balloon-first (hazard ratio for drug-eluting stent vs drug-coated balloon 2.01, 95% confidence interval 1.21–3.42; Cox p=0.008). Here’s the trade-off: these differences are clinically meaningful in a long-lesion setting, but residual confounding remains possible despite weighting and prespecified sensitivity analyses.
Conclusion
In de novo diffuse left anterior descending disease, a drug-coated balloon-first strategy achieved comparable procedural success and was associated with lower 12-month major adverse cardiovascular events and repeat revascularisation than drug-eluting stenting. These real-world data support a "leave-nothing-behind" option in selected long lesions, while randomised trials with protocolised angiographic follow-up are needed to confirm durability and clarify which anatomical subsets benefit most.Adjusted cox model for time to mACE.For image description, please refer to the figure legend and surrounding text.MACE-free survival and propensity scoreFor image description, please refer to the figure legend and surrounding text.