Back to the future: Revisiting "leave nothing behind" when managing coronary artery disease

Despite major technological advances, contemporary drug-eluting stents (DES) remain intrinsically limited by the permanent implantation of a metallic prosthesis, exposing patients to chronic vessel caging, impaired vasomotion, neoatherosclerosis, and persistent risks of restenosis and late thrombotic events. These limitations have renewed interest in implant-sparing coronary revascularization based on the "leave-nothing-behind" concept. Drug-coated balloons (DCB) have emerged as the most mature implant-free technology, with robust evidence supporting their use beyond in-stent restenosis and small-vessel disease to increasingly complex clinical scenarios, including chronic total occlusions, diffuse coronary artery disease, bifurcation lesions, diabetes mellitus, and patients at high bleeding risk. Successful DCB angioplasty, however, depends on meticulous lesion preparation, tailored plaque modification, and selective intracoronary imaging to optimize procedural outcomes. In parallel, new-generation bioresorbable scaffolds (BRS) and bioadaptors are revitalizing the concept of temporary vessel scaffolding. By incorporating thinner struts, improved mechanical properties, enhanced biocompatibility, and restoration of vascular physiology following resorption or uncaging, these technologies aim to overcome the thrombotic limitations that hindered first-generation devices. This review provides a comprehensive overview of the biological rationale, current clinical evidence, procedural optimization, and future perspectives of implant-sparing PCI, highlighting the ongoing transition from a device-centered strategy to a personalized, morphology-guided approach in which lesion characteristics, vascular biology, and patient-specific risk drive revascularization decision-making.