Drug-Coated Balloons in Chronic Total Occlusions: A Narrative Review

Chronic total occlusions (CTOs) are often treated with long, overlapping drug-eluting stents (DES), increasing metal burden and potentially limiting vasomotion and future revascularization. Drug-coated balloons (DCBs) offer a metal-sparing alternative by delivering an antiproliferative drug without a permanent implant. This narrative review summarizes the mechanistic rationale and current clinical evidence for DCB use in CTO PCI, including de novo CTOs, in-stent CTOs (ISR-CTOs), and hybrid DCB-DES strategies. In selected de novo CTOs, DCB-only treatment after successful recanalization and meticulous lesion preparation appears feasible, with frequent late lumen enlargement. In ISR-CTOs, DCB angioplasty appears broadly comparable to repeat DES implantation while avoiding additional metallic layers. Hybrid strategies may reduce total stent length with comparable mid-term outcomes. However, most CTO data are observational and influenced by selection bias, surveillance intensity, and heterogeneous endpoint definitions, while CTO-specific randomized evidence remains limited. DCB-based CTO PCI should therefore be regarded as an option for carefully selected lesions rather than a standard strategy for all CTOs. Randomized trials with standardized procedural definitions and longer follow-up are needed to define the roles of DCB-only, hybrid, and full-DES strategies in contemporary CTO practice.