Drug-coated balloons for coronary bifurcation lesions

Coronary bifurcation lesions (CBLs) represent a common and challenging subset of coronary artery disease requiring percutaneous coronary intervention (PCI). While drug-eluting stents (DES) remain the cornerstone of treatment, their use is associated with risks such as restenosis, thrombosis, side branch (SB) jailing and the need for prolonged dual antiplatelet therapy. Drug-coated balloons (DCBs) have emerged as a promising alternative, delivering antiproliferative drugs without permanent implants, thereby reducing the risk of late complications and preserving native vessel geometry. This review explores the role of DCBs in CBL management, particularly for SB treatment within the provisional stenting strategy. Evidence from clinical studies indicates that DCBs significantly reduce late lumen loss and restenosis in the SB compared to plain balloon angioplasty, while simplifying PCI procedures and avoiding extensive stenting. Furthermore, hybrid/blended strategies combining DCBs with DES have shown superior clinical and angiographic outcomes in true CBLs compared to DES-only approaches. Despite their potential, the adoption of DCBs faces challenges, including the need for optimal lesion preparation and a lack of standardised procedural techniques. Existing randomised controlled trials are limited by small sample sizes, design heterogeneity, inclusion of bare metal stents either as comparators or as part of the treatment strategy, and inconsistent use of key procedural steps such as proximal optimisation technique and kissing balloon inflation. This manuscript aims to provide interventional cardiologists with practical guidance for managing CBLs, focusing on the effective integration of DCBs into standalone and hybrid strategies. By emphasising procedural optimisation and complication reduction, this review seeks to promote more standardised and reproducible approaches in clinical practice.