Drug-Coated Balloon Versus Newer-Generation Drug-Eluting Stent Following Directional Coronary Atherectomy for Left Main Bifurcation Lesions.

Directional Coronary Atherectomy (DCA) is a potential treatment option for left main (LM) bifurcation lesions, as it may prevent side branch occlusion and reduce the need for complex stenting. Recent studies have suggested that combining drug-coated balloon (DCB) with DCA can lead to favorable cardiovascular outcomes. However, the comparative efficacy of DCB and current drug-eluting stents (DES) following DCA for LM bifurcation lesions remains unclear. This study aimed to compare the clinical outcomes of DCB and DES following DCA for LM bifurcation lesions. A retrospective analysis was conducted on 109 patients treated with DCA for LM bifurcation lesions from 2016 to 2024. Patients were divided into groups of DCA+DCB (n = 58) and DCA+DES (n = 51). The primary endpoint was ischemia-driven target lesion revascularization (ID-TLR), and the secondary endpoint was target lesion-related myocardial infarction (TLMI). Lesion characteristics were evaluated using quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). Kaplan-Meier analysis revealed higher ID-TLR occurrence at 5 years in the DCA+DCB group than the DCA+DES group (16.4% vs 2.3%, P = 0.027). In contrast, TLMI occurrence was similar (4.7% vs 2.3%, p = 0.667). The DCA+DCB group exhibited greater residual diameter stenosis (24.4% vs 16.3%, p <0.001) on QCA and smaller minimum lumen area (7.33 mm² vs 8.42 mm², p <0.001) and greater residual plaque area (48.9% vs 45.3%, p = 0.027) on IVUS compared to the DCA+DES group. In conclusion, the DCA+DCB strategy was associated with a higher ID-TLR incidence and a smaller luminal gain than DCA+DES. Although DCA+DCB provides a stent-less alternative, long-term monitoring is essential to address its limitations.