In ACS patients treated with PCI, early discontinuation of aspirin while maintaining P2Y12 inhibitor monotherapy appears to reduce adverse clinical events compared with standard 12-month DAPT. These findings show net benefit of following early aspirin discontinuation strategy due to reduction in major bleeding events without jeopardizing ischemic outcomes.

Dual antiplatelet therapy (DAPT) is the combined use of aspirin and an oral P2Y12 receptor inhibitor. It is central to the prevention of platelet-mediated coronary thrombosis after acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). The clinical rationale for DAPT is particularly strong after ACS and coronary stent implantation. ACS is associated with a high risk of platelet-driven atherothrombosis, while interruption of antiplatelet therapy after recent stenting is associated with increased risk of major adverse cardiovascular events (MACE) and stent thrombosis. Premature DAPT interruption is described as the strongest predictor of stent thrombosis in this setting.

Coronary artery disease remains the leading cause of global morbidity and mortality, traditionally managed through percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, this review emphasizes that optimal medical therapy (OMT) is equally critical to revascularization outcomes. Contemporary OMT encompasses antiplatelet agents or dual antiplatelet therapy, lipid-lowering drugs for all patients, beta-blockers, and ACE inhibitors or angiotensin receptor blockers for most patients, alongside cardiac risk factor management and lifestyle modifications. For stable angina patients, OMT represents the recommended initial approach, with revascularization indicated only if symptoms persist despite optimal therapy or prognosis requires improvement. For acute coronary syndrome patients and those undergoing revascularization, long-term OMT substantially improves clinical outcomes and prognosis. The article examines OMT's evolution and contemporary role in clinical practice, highlighting that while mechanical revascularization procedures have transformed CAD treatment, the concomitant use of evidence-based optimal medical therapy remains vital for maximizing patient outcomes and preventing misconceptions about treatment superiority.

The evolution of drug-eluting stents (DES) has fundamentally transformed interventional cardiology, yet questions remain about long-term comparative effectiveness. Early-generation DES, including sirolimus-eluting stents (CYPHER®) and paclitaxel-eluting stents (TAXUS™), reduced restenosis compared to bare metal stents but increased very late stent thrombosis risk. The Endeavor® zotarolimus-eluting stent (E-ZES) presented a notable exception with a more favorable safety profile. Contemporary new-generation DES employ thin metallic platforms using cobalt-/platinum-chromium alloys, biocompatible biodegradable polymers, and limus analogues, demonstrating improved efficacy and safety. As clinical trial methodology advances with all-comer populations and registry-based randomized controlled trials, extended follow-up data become critical for understanding time-dependent adverse events like stent thrombosis and repeat revascularization. The SORT OUT III trial now provides 10-year follow-up findings, building on previous studies such as SYNTAX, SIRTAX, and SORT OUT II. These extended observations are essential for determining optimal duration of ancillary medical therapy and establishing whether all contemporary DES perform equivalently during prolonged follow-up periods.

This clinical trial investigates optimal antiplatelet therapy management following ST-elevation myocardial infarction (STEMI) treatment. When STEMI patients undergo percutaneous coronary intervention with stent placement, they typically receive dual antiplatelet therapy (DAPT) for an extended period. The study examines whether abbreviated DAPT lasting one to 1.5 months followed by monotherapy with prasugrel alone matches the safety and efficacy of conventional prolonged dual therapy while potentially reducing bleeding complications. For patients with multi-vessel disease requiring treatment of additional narrowed arteries, the trial also compares optical coherence tomography (OCT) imaging guidance against standard angiography to determine which approach yields superior outcomes. Eligible participants must present with acute STEMI, demonstrate electrocardiographic changes, and successfully complete initial revascularization of the culprit lesion. After completing abbreviated DAPT without major adverse events or significant bleeding, patients proceed to randomization. This research addresses the critical challenge of balancing thrombotic prevention against bleeding risk in post-STEMI management, potentially refining treatment strategies for improved long-term patient safety and outcomes while reducing the burden of prolonged dual antiplatelet therapy.

Two recent studies published in JACC: Cardiovascular Interventions examined angiography-derived fractional flow reserve (FFR) as an alternative to wire-based FFR for coronary artery disease assessment. The PROVISION trial randomized 401 Japanese patients across 13 centers to compare both strategies, demonstrating that angiography-derived FFR was noninferior to wire-based FFR for guiding revascularization in stable CAD. Revascularization rates were comparable at 41% versus 38%, with one-year major adverse cardiovascular events occurring in 8.4% versus 10.1% respectively. Notably, angiography-derived FFR reduced median radiation exposure from 34.8 to 28.3 Gy·cm², though it required slightly longer procedure times. A separate analysis of the J-PRIDE registry involving 3,200 patients explored discordance between FFR and nonhyperemic pressure ratios (NHPR), revealing clinically significant prognostic information when results diverge. These findings suggest angiography-derived FFR offers a practical, lower-radiation alternative to invasive wire-based assessment, though experts emphasize the importance of longer-term follow-up to fully understand risks associated with discordant cases.

This prospective, multi-center, randomized study compares the Virtue® Sirolimus AngioInfusion™ Balloon (SAB) with the AGENT™ Paclitaxel Drug-Coated Balloon (DCB) for treating coronary in-stent restenosis (ISR). The non-inferiority trial enrolls patients with single or double-layer ISR in native coronary arteries previously treated with drug-eluting or bare metal stents, targeting lesions between 2.0–4.0 mm in diameter and ≤26 mm in length. Eligible patients must demonstrate significant stenosis (≥70% or ≥50% with abnormal FFR, iFR, or RFR values) and receive successful pre-treatment with residual stenosis ≤30%. The study excludes patients with severely reduced ejection fraction, recent PCI, planned revascularization, acute myocardial infarction within specific timeframes, previous restenosis treatments beyond balloon angioplasty, graft locations, or thrombus presence. This trial is clinically significant as it directly compares two advanced drug-coated balloon platforms to establish the most effective treatment strategy for ISR, a common complication affecting long-term outcomes in coronary intervention patients.

The long-term complications associated with stent implantation for the treatment of coronary and peripheral artery disease have prompted a search for more conservative treatments, and a ‘leave nothing behind’ strategy. Drug-coated balloons are an attractive alternative that combine the advantages of balloon angioplasty with inhibition of neointimal proliferation and restenosis. Paclitaxel has so far been the drug of choice in balloon coating, given its high lipophilicity and local tissue retention. Still, its use is limited by a narrow therapeutic window and safety concerns. Sirolimus-coated balloons entered the drug-coated balloon arena late because of the need to use specific technologies to overcome pharmacokinetic limitations. Their use was initially tested in in-stent restenosis and small-calibre native vessels, demonstrating results that overlapped with those obtained with paclitaxel-coated balloons in terms of efficacy. New indications for sirolimus-coated balloon angioplasty are emerging, such as acute coronary syndromes, coronary bifurcations, peripheral and coronary medium- to large-calibre native vessels, critical limb ischaemia, vasculogenic erectile dysfunction, and dysfunctional arteriovenous fistulas. Data in these areas are still limited to small, non-randomised studies, showing encouraging results.

Because of their capacity to deliver antiproliferative agents locally, without the long-term presence of a metallic scaffold, has redefined treatment strategies for in-stent restenosis (ISR), small vessel disease (SVD), de novo lesions, and bifurcation segments, reducing the incidence of late and very late stent-related complications, such as thrombosis and neoatherosclerosis [24]. By eliminating permanent implants, DCBs allow for shorter durations of dual antiplatelet therapy (DAPT), a critical advantage in high-bleeding-risk (HBR) patients. Recent evidence suggests that sirolimus-based DCBs may provide superior vascular healing and broader applicability compared to paclitaxel-based DCBs, but further research must clarify this.

In conclusion, sirolimus-coated DCBs are poised to expand the DCB paradigm, building on the strong foundation laid by paclitaxel DCBs. Current evidence and guidelines already support DCB (especially DCB-P) in ISR and small vessels, and use in de novo CAD is growing as large trials demonstrate non-inferiority to DES [5]. In ACS, DCB-only PCI is an intriguing strategy that challenges the conventional need for a stent in every infarct. Studies show it can work in carefully selected cases with diligent technique [17]. Sirolimus DCBs, with improved delivery kinetics, have shown for the first time that a limus-drug balloon can effectively compete with DES in broad populations [3]. They offer the possibility of a metal-free intervention with a drug most interventionalists are already comfortable with (as used on DES). As more data emerge, we may see guideline updates granting DCB-S a role alongside DCB-P. Ultimately, the interventional community is moving toward an era of precision PCI, selecting the right tool (DES, DCB-P, or DCB-S) for each lesion and patient. In this context, drug-coated balloons (of either drug) are an increasingly important part of the armamentarium, enabling effective revascularization while leaving nothing behind except the drug’s effect. The continued refinement of DCB technology and technique holds the promise of improving long-term outcomes and freedom from reinterventions for our patients with coronary artery disease.

Percutaneous coronary intervention (PCI) workflows exhibit significant variation across institutions and operators, particularly in lesion assessment, procedural planning, and management of complex coronary lesions including bifurcations, calcified vessels, and chronic total occlusions. Leading interventional cardiologists from WellSpan Health, University of Pennsylvania, and Duke University address optimization opportunities in contemporary PCI practice. While standardized decision-making frameworks are beneficial for patient selection, physiologic assessment, imaging-guided stent optimization, and quality reporting, technical execution must remain flexible to accommodate individual anatomical and patient variations. A critical gap exists in intravascular imaging (IVI) adoption despite its Class I guideline recommendation in 2025 multisociety guidelines. Currently, IVI is employed in only 20 percent of PCIs nationwide, despite evidence demonstrating cardiovascular benefits comparable to intensifying statin therapy and substantially reducing stent-related complications. Additionally, persistent reliance on angiographic visual assessment for lesion severity evaluation perpetuates operator variability dating to the 1970s, influencing revascularization decisions. Incorporating physiology-guided decision-making and standardizing IVI utilization represent key opportunities to improve procedural consistency and patient outcomes while maintaining the necessary procedural flexibility essential for complex coronary anatomy.

A systematic review and meta-analysis examined drug-coated balloons (DCBs) coated with paclitaxel or sirolimus against drug-eluting stents (DES) for treating acute myocardial infarction. Following PRISMA 2020 guidelines, researchers analyzed 34 studies (14 randomized controlled trials, 20 observational cohorts) comprising 19,642 participants and 2,313 major adverse cardiovascular events. DCBs demonstrated a 15% relative reduction in MACE compared to DES, with rates of myocardial infarction, target lesion revascularization, and cardiovascular mortality remaining comparable between groups. Notably, late stent thrombosis was significantly lower with DCBs. Most evidence involved paclitaxel-coated balloons; sirolimus-coated data remain limited. DCBs offer a promising stent-free percutaneous coronary intervention strategy, eliminating permanent scaffolds while reducing late thrombosis risk and extended dual antiplatelet therapy requirements. The findings suggest DCBs provide comparable safety and efficacy to DES, though device selection should consider lesion complexity and bleeding risk. Larger randomized trials specifically evaluating sirolimus-coated DCBs are needed to strengthen evidence.

Researchers from Istanbul Medipol University conducted a retrospective study examining treatment strategies for in-stent restenosis, a persistent complication despite advances in drug-eluting stent technology. The study compared paclitaxel-coated drug-coated balloon angioplasty with ultrathin-strut sirolimus-eluting stents in 205 patients with stable angina treated between 2015 and 2025. Over a median follow-up of 863 days, target-lesion revascularization rates were comparable overall; however, outcomes diverged significantly based on restenosis pattern. In non-focal in-stent restenosis, ultrathin-strut sirolimus-eluting stents demonstrated substantially better results, with target-lesion revascularization rates of 12.7% versus 34.1% for drug-coated balloons and major adverse cardiac events of 18.2% versus 39.0% respectively. No meaningful differences emerged in focal restenosis cases. Multivariable analysis identified drug-coated balloon treatment as an independent predictor of repeat revascularization in non-focal lesions. These findings emphasize that optimal in-stent restenosis management should be tailored to specific lesion characteristics, potentially favoring ultrathin-strut drug-eluting stents for diffuse disease patterns while maintaining flexibility in treatment selection.

B Braun has initiated the BASKET BALL trial, an international randomized multicentre study enrolling 2,184 patients across up to 60 sites in 15 countries to evaluate its sirolimus-coated balloon SeQuent SCB in complex coronary artery disease. Led by Raban Jeger and Bruno Scheller, the trial compares a drug-coated balloon-only strategy with potential stent crossover against a standard drug-eluting stent approach, measuring target vessel failure and major bleeding at 12 and 36 months. The trial addresses a critical clinical question by testing whether DCB-based treatment offers non-inferiority to traditional DES strategies in high-risk patients. Building on B Braun's extensive DCB evidence portfolio comprising over 145 clinical studies, SeQuent SCB has demonstrated non-inferiority to earlier SeQuent formulations across five randomized trials. The BASKET BALL enrollment and recently presented one-year SCORE results represent significant milestones in expanding the clinical evidence supporting drug-coated balloon treatment in coronary artery disease, potentially reshaping interventional cardiology practices.

The 15th European Bifurcation Club meeting, held in Barcelona in October 2019, delivered updated consensus recommendations on coronary bifurcation lesion treatment and unprotected left main percutaneous coronary interventions. For most patients, a provisional approach with optional side branch treatment using TAP or culotte techniques remains optimal, offering flexibility while debate continues regarding side branch assessment and bail-out treatment thresholds. In complex bifurcation lesions, particularly those involving the left main, dedicated two-stent techniques warrant consideration, though operators must master procedural steps and acknowledge limitations. Final kissing inflation is considered mandatory when employing two-stent strategies to prevent compromised outcomes. Emerging technologies including intracoronary imaging, bifurcation simulation, drug-eluting balloon technology, and tailored antiplatelet therapy show promise for enhancing clinical results. Since its establishment in 2004, the European Bifurcation Club has systematized bifurcation PCI through evidence-based research spanning bench testing to randomized controlled trials, though further innovation remains necessary to optimize patient outcomes across all bifurcation interventions.

Percutaneous coronary intervention (PCI), also known as percutaneous transluminal coronary angioplasty (PTCA), is a minimally invasive procedure used to treat coronary artery disease with or without stent insertion. The procedure addresses stable ischemic heart disease with refractory angina and acute coronary syndromes including unstable angina, NSTEMI, and STEMI. For STEMI patients, stent placement within 90 minutes of symptom onset represents optimal treatment. Elective PCI is appropriate for post-MI patients with recurrent angina or those remaining symptomatic despite medical management. The procedure is typically performed via femoral, radial, or brachial artery puncture, with the radial approach now preferred due to reduced patient discomfort, faster ambulation, and decreased bleeding complications. A guiding catheter is threaded to the coronary artery, followed by inflation of a balloon-tipped catheter guided by fluoroscopy or intravascular ultrasound to disrupt atherosclerotic plaque and dilate the artery. A stent is usually placed to maintain vessel patency, with post-procedure angiography confirming successful revascularization.

Fractional flow reserve (FFR) is an established technique for guiding coronary interventions by identifying lesion-level ischaemia, though its application in acute coronary syndrome (ACS) remains controversial. This comprehensive review examines FFR efficacy in both non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) settings. The analysis confirms FFR as a reliable tool for lesion-level decision-making in NSTEMI, though with specific limitations. For STEMI, evidence remains limited, but FFR shows potential value in assessing non-culprit lesions in stabilized patients post-intervention. Notably, the index of myocardial resistance (IMR), measured in the culprit artery, demonstrates predictive value for long-term clinical outcomes in STEMI patients. The review addresses multivessel disease, present in 30-50% of STEMI presentations with associated worse prognosis. The findings support an increasing evidence base for FFR-guided revascularization and IMR-based outcome prediction in ACS patients, while acknowledging concerns about microvascular pathophysiology affecting maximal hyperaemia induction and plaque instability considerations.

The GINGER trial evaluated the efficacy of a novel sirolimus-eluting balloon (SEB) incorporating phospholipid nanocarriers for treating long de novo coronary artery disease. This prospective study assessed a next-generation drug-delivery system designed to improve therapeutic outcomes in complex coronary lesions. Sirolimus, an immunosuppressant with anti-proliferative properties, was delivered via advanced phospholipid nanocarrier technology to enhance drug retention and bioavailability at the treatment site. The phospholipid nanocarrier platform represents a significant advancement in balloon angioplasty technology, enabling sustained drug release while minimizing systemic exposure. By targeting long coronary lesions that traditionally require stent implantation, this innovation offers a potentially less invasive alternative. The trial's prospective design and focus on de novo lesions provide clinically relevant data for interventional cardiologists seeking to expand treatment options for complex coronary disease. Results from GINGER contribute to the growing body of evidence supporting drug-eluting balloon technology as a viable strategy for improved patient outcomes and reduced long-term complications in coronary intervention.

Artificial intelligence is being progressively integrated across interventional cardiology, from pre-procedural planning through post-procedural monitoring and clinical decision support. The maturity of evidence varies substantially across applications. Computed tomography-derived and angiography-derived physiological assessment, selected automated image-analysis tools, and operator-controlled robotic assistance have demonstrated prospective or real-world evidence in specific settings, while digital twins, hybrid intravascular ultrasound-optical coherence tomography interpretation, generative simulations, autonomous robotic control, and large language model-based reasoning remain at earlier validation stages. This review examines AI applications throughout the interventional cardiovascular care pathway and critically evaluates supporting evidence, while addressing translational barriers including dataset heterogeneity, workflow integration, cost-effectiveness, cybersecurity, regulatory oversight, and clinician trust. Rather than viewing AI monolithically, the authors propose an evidence-calibrated framework distinguishing clinically implemented tools from investigational platforms. Future adoption should prioritize prospective validation, transparent evidence grading, reproducibility, regulatory clarity, and demonstrable patient-centered outcomes over algorithmic novelty alone. As interventional cardiology advances toward increasingly complex catheter-based therapies, AI's clinical value depends on specific task validation and outcome improvement rather than computational performance.

Biological safety evaluations remain one of the most expensive and time-consuming phases of medical device development. Traditional approaches that involve full biocompatibility test panels can cost from $150k up to $500k per device and add an additional 3 to 18 months to development timelines. Costs and timeline implications are constraining device launches across the industry. Startups are forced into repeated funding cycles, while established companies face rising expenses to sustain multiple product portfolios.