Innovative approaches to percutaneous bifurcation interventions using drug-eluting balloons.

Coronary bifurcations are frequently found complex coronary lesions that continue to be associated to worse outcomes than simpler ones, despite dedicated techniques and use of drug-eluting stents (DES). Moreover, besides concerns regarding DES thrombosis and late restenosis in complex lesions, several issues might limit DES use in real world conditions. If a widespread use of DES might therefore appeared unjustified, local treatment by an anti-proliferative drug remains attractive. This is the reason why drug-eluting balloons (DEB) have been developed, with several potential advantages over DES including homogeneous drug transfer to the vessel wall with local drug delivery over a very short period of time and absence of both a polymer matrix and a metal platform. When approaching bifurcation lesions, actual evidences do not support increased benefit of a two-stent technique over stenting the main vessel only. However, provisional stenting is often associated with suboptimal results in the side branch, thus leaving room for some improvement that could be very well managed by drug-eluting balloon technology. To date, two different approaches to percutaneous bifurcation intervention with DEB have been developed, namely sequential DEB treatment of the bifurcation branches followed by provisional bare metal stent implantation and simple main vessel stenting followed by kissing DEB. The kissing DEB approach has also shown promising results in the treatment of bifurcation restenosis that represent particularly challenging lesions to treat. Available data suggest that DEB offers a new opportunity to implement innovative, simpler and possibly safer and more effective percutaneous bifurcation interventions.