Stentless Angioplasty with Drug-Coated Balloons (DCB)

A drug-coated balloon can treat some coronary artery narrowings without adding a new stent. Whether this is suitable depends on the blockage, the evidence for that type of narrowing, and how the artery responds during treatment.

“Can this be treated without a stent?”

If you have been advised angioplasty, it is reasonable to ask this. It is equally important to understand when a stent gives the artery the support it needs. The aim is a safe, lasting result suited to your heart.

Dr. Kulin Sheth performs DCB angioplasty at Apollo CVHF Hospital, Bodakdev, Ahmedabad. His practice includes selected DCB-only procedures and hybrid treatment combining a drug-eluting stent with a drug-coated balloon.

It is a form of coronary angioplasty in which a suitable narrowing is treated with a drug-coated balloon, without implanting a new stent at that site.

Is it suitable for every blockage?
No. DCB has an established role in selected cases of narrowing inside an existing stent and evidence supporting selected previously untreated small arteries. Other blockages may be better treated with a drug-eluting stent or another approach.

Can a stent still be needed?
Yes. Even when DCB is planned, a stent may be needed if the artery does not stay adequately open or blood flow is compromised.

A drug-coated balloon, or DCB, is an angioplasty balloon carrying medicine that helps reduce tissue growth responsible for repeat narrowing. The balloon delivers this medicine to the artery wall and is then removed.

The procedure takes place through a catheter introduced into an artery, usually at the wrist or sometimes at the groin. Local anaesthetic numbs the entry site, and you are usually awake. There is no opening of the chest.

The main steps are:

1. The cardiology team assesses the narrowing and prepares it with an appropriate balloon or other tools when needed.
2. The artery is checked to see whether it has opened adequately and blood is flowing well.
3. If the result is suitable, a drug-coated balloon is inflated across the prepared segment to deliver medicine.
4. The balloon is removed and the final result is assessed. A stent is used if the artery needs additional support.

In a previously untreated segment, successful DCB-only treatment leaves no new permanent implant. If DCB is used inside an existing stent, the old stent remains in place. DCB does not dissolve or remove it.

The catheter-based approach is similar to other forms of coronary angioplasty and PCI. The difference is how the prepared narrowing is treated.

Narrowing inside an existing stent

An artery can narrow again within a previously placed stent. This is called in-stent restenosis. Possible causes include tissue growth, new plaque developing within the stented segment, or a stent that has not expanded adequately.

DCB is an established treatment option in selected cases and can avoid adding another metal layer. However, another drug-eluting stent may offer a more durable result in some patients, particularly when the narrowed original implant is itself a drug-eluting stent. Current European guidance favours repeat drug-eluting stenting over DCB for this situation, while expert consensus recognises a role for DCB after individual assessment.

The first question is why the narrowing happened. Imaging from inside the artery, using IVUS or OCT, can help identify the cause and guide treatment. A drug-coated balloon alone cannot correct a stent that remains mechanically underexpanded.

A previously untreated narrowing in a small artery

A small coronary artery has less room for further narrowing after treatment. In selected patients, DCB can treat the blockage without placing a new implant in that segment.

Randomised trials, including BASKET-SMALL 2, support this approach after satisfactory preparation of the narrowing. These results apply to the patients and devices studied. They do not mean that every small artery is suitable for DCB.

Other previously untreated blockages

DCB may be considered for other carefully selected narrowings, but the evidence is less consistent than a simple “stent versus no stent” comparison suggests.

In the broader REC-CAGEFREE I trial, a DCB strategy with rescue stenting when needed produced more adverse events than planned drug-eluting stenting through three years. This is an important reason not to offer DCB routinely as a replacement for a stent in all untreated blockages.

Before choosing a device, the team also considers whether the narrowing needs an intervention at all. Symptoms, the effect on blood supply, heart function and the overall pattern of coronary artery disease help determine whether medicines, PCI or bypass surgery is appropriate.

An angiogram provides important information, but the decision is not based only on how severe a blockage looks in one image.

The assessment includes:

• Where the narrowing is, the artery's size and the length of the affected segment.
• Whether it is a new narrowing or repeat narrowing inside a stent.
• Calcium, previous stent layers and the underlying reason for restenosis.
• Symptoms, blood supply to the heart muscle and heart pumping function.
• Bleeding risk, kidney function and the medicines you can safely take.
• The result after preparing the narrowing, including remaining narrowing, recoil, blood flow and any tear in the artery lining.

Tests of blood flow or imaging inside the artery may help where appropriate. These are selected according to the clinical question.

Some decisions can be discussed before treatment. Others depend on what happens when the artery is opened. A plan to consider DCB cannot guarantee that no stent will be required.

Both deliver medicine to reduce repeat narrowing. A drug-eluting stent also provides a permanent framework to support the artery.

Avoiding another implant can be useful in the right setting. It does not make DCB inherently safer or more effective for every patient.

After balloon treatment, the artery may spring back towards its narrowed shape. This is called recoil. There may also be too much narrowing left, inadequate blood flow, or a tear in the artery lining that compromises the result.

A small tear with good blood flow does not automatically require a stent. The team assesses its extent, the stability of the artery and the overall result.

If the artery needs support, inserting a stent is a safety decision. This possibility should be discussed before a planned DCB procedure, including consent for a stent if necessary.

Some patients have different treatment needs in different segments or branches of their coronary arteries. A drug-eluting stent may be used where support is required, with a DCB used in another suitable segment or branch. This is called a hybrid strategy.

Dr. Kulin uses hybrid stent-plus-DCB treatment in selected cases. The choice depends on the anatomy, the evidence relevant to the narrowing and the result achieved during treatment.

A hybrid procedure still leaves a stent in the area where it was implanted. It should not be described as an entirely stentless procedure. Medicines after treatment must account for both parts of the procedure.

These situations need additional planning. DCB may be part of treatment in selected cases, but its suitability cannot be assumed from the diagnosis alone.

Heavily calcified arteries: Calcium can prevent a balloon from opening a narrowing adequately. Preparation may involve cutting or scoring balloons, rotational atherectomy (rotablation) or intravascular lithotripsy (IVL), depending on the calcium and anatomy. These tools address the mechanical problem. A DCB delivers medicine; it does not replace calcium preparation.

Chronic total occlusions (CTOs): Once a completely blocked artery has been crossed and prepared, DCB may be considered for selected segments, sometimes as part of a hybrid approach. Evidence is less established than for its core uses, and successful crossing alone does not establish suitability.

Branching arteries and left-main disease: Treatment must protect blood flow to the relevant branches and heart muscle. A stent, a selected combination of stent and DCB, or bypass surgery may be considered according to the individual case. DCB is not a routine substitute for a stent or bypass in left-main disease.

These decisions belong within a broader assessment of complex and high-risk PCI.

Bring your angiogram report and images, previous procedure reports, stent details if available, current prescription and recent blood tests. Tell the team about kidney disease, previous contrast reactions, bleeding problems, diabetes and any planned surgery.

You will receive individual instructions about food, drink and medicines. Do not stop or change antiplatelets, anticoagulants or diabetes medicines on your own. Kidney disease may require additional assessment and measures to reduce the risk of contrast-related kidney injury.

Before treatment, discuss the reason for PCI, the proposed DCB or hybrid strategy, alternatives and the possibility of needing a stent. The procedure preparation guidance supports your team's individual instructions.

Yes. No new stent does not mean no medicines.

Antiplatelet medicines reduce the risk of clots while the treated artery heals. Aspirin and another antiplatelet medicine may be prescribed together for a period. Some selected patients having DCB-only treatment for stable disease can use a shorter course of two antiplatelet medicines, but there is no single duration suitable for everyone.

The plan depends on whether treatment followed a heart attack, bleeding risk, existing stents, any new stent, other medicines and the final procedural result. Selected patients with modern drug-eluting stents can also receive shorter courses, so a shorter course should not be presented as an automatic advantage of DCB.

If you already take an anticoagulant, such as for atrial fibrillation, the combination needs particular care. Anticoagulants and antiplatelets have different roles and should not be substituted for one another without medical advice.

Your discharge prescription should make clear which medicines to take, for how long and when they will be reviewed. Do not stop them because you feel well or because no new stent was implanted. Discuss bleeding or side effects promptly.

Cholesterol-lowering treatment and control of blood pressure, diabetes and smoking remain important. DCB treats a particular narrowing. It does not cure the underlying coronary artery disease.

Recovery and Returning to Your Routine

Recovery is broadly similar to other coronary angioplasty procedures. The absence of a new stent does not by itself mean a shorter hospital stay or faster return to normal activity.

Discharge depends on your symptoms, the access site, the complexity and result of treatment, kidney function and whether you have had a heart attack. Wrist access often allows earlier mobilisation once the team confirms it is safe.

Gentle walking and a gradual return to routine are usually encouraged after an uncomplicated procedure. Returning to desk work differs from returning to heavy manual work. You will receive instructions about lifting, exercise, driving and care of the wrist or groin puncture site. After a heart attack or a more complex procedure, recovery may take longer.

Follow-up reviews check symptoms, medicine tolerance and risk-factor control. Cardiac rehabilitation can help you rebuild confidence and activity safely. The recovery and follow-up guidance provides further practical information.

When should I seek urgent help?

Seek emergency medical care for persistent or severe chest pain, chest discomfort with sweating or breathlessness, severe breathlessness, collapse, or new stroke symptoms. Do not wait for a routine appointment or a second opinion.

Urgent assessment is also needed for bleeding from the puncture site that does not stop with firm pressure, rapidly increasing swelling, or a cold, numb or painful hand or leg. Do not drive yourself if you are seriously unwell.

DCB angioplasty has risks associated with coronary catheter procedures, including bleeding, injury to the artery, contrast reactions, kidney injury, abnormal heart rhythms and heart attack. Serious complications can include stroke, emergency surgery or death. Your individual risk depends on your health, heart function and the complexity and urgency of treatment.

Specific limitations include recoil, a tear affecting blood flow, sudden vessel closure, an inadequate result requiring a stent, and repeat narrowing requiring further treatment. DCB does not eliminate clotting risk or guarantee that another procedure will never be needed.

The medicines and coatings used by different DCB devices are not identical. Evidence for one device and one clinical situation should not be assumed to apply to every balloon or every type of blockage.

You may want a second opinion if a previous stent has narrowed, if you have been offered DCB or another stent, or if you are trying to understand whether a hybrid approach or bypass would suit your situation.

Dr. Kulin personally reviews existing reports and angiogram images before deciding whether any further assessment is appropriate. Bring your previous procedure records, stent details and current medicines as well.

The discussion can address why treatment is being advised, the cause of repeat narrowing, the evidence for each option, the possibility of a stent during DCB treatment, and the implications for medicines and recovery. Some aspects of suitability can only be confirmed during the procedure.

For a planned review, arrange a consultation with Dr. Kulin Sheth. Ongoing or worsening symptoms that could represent a heart attack need urgent care rather than an elective appointment.

References

• 2024 ESC Guidelines for the management of chronic coronary syndromes
• SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis
• DAEDALUS: paclitaxel-coated balloon angioplasty versus drug-eluting stenting for coronary in-stent restenosis
• BASKET-SMALL 2: three-year comparison of drug-coated balloons and drug-eluting stents in small coronary arteries
• REC-CAGEFREE I: three-year follow-up of drug-coated balloon angioplasty versus planned stenting for previously untreated coronary disease
• Drug-Coated Balloons-Based Intervention for Coronary Artery Disease: Second Report of the Asia-Pacific Consensus Group, 2025
• FDA safety and effectiveness documentation for the AGENT coronary drug-coated balloon
• NHS guidance on recovery after coronary angioplasty

Medically reviewed by Dr. Kulin Sheth, MD, DrNB Cardiology.