Predictors of bail‐out stenting in patients with small vessel disease treated with drug‐coated balloon percutaneous coronary intervention

Abstract Background Drug‐coated balloons (DCBs) have shown comparable results with drug‐eluting stents in small vessel disease (SVD) percutaneous coronary intervention (PCI) in terms of target vessel revascularization and a reduced incidence of myocardial infarction. However, the relatively high rate of bail‐out stenting (BOS) still represents a major drawback of DCB PCI. Aims The aim of the study was to investigate the clinical, anatomic, and procedural features predictive of BOS after DCB PCI in SVD. Methods We included all consecutive patients undergoing PCI at our institution between January 2020 and May 2022 who were treated with DCB PCI of a de novo lesion in a coronary vessel with a reference vessel diameter (RVD) between 2.0 and 2.5 mm. Angiographic success was defined as a residual stenosis <30% without flow‐limiting dissection. Patients who did not meet these criteria underwent BOS. Results A total of 168 consecutive patients and 216 coronary stenoses were included. The rate of bail‐out stent was 13.9%. On multivariate analysis, DCB/RVD ratio (odds ratio [OR]: 4.39, 95% confidence interval [CI]: 1.71–11.29, p < 0.01), vessel tortuosity (OR: 7.00, 95% CI: 1.66–29.62, p < 0.01), distal vessel disease (OR: 5.66, 95% CI: 2.02–15.83, p < 0.01), and high complexity (Grade C of ACC/AHA classification) coronary stenoses (OR: 6.31, 95% CI: 1.53–26.04, p = 0.01) were independent predictors of BOS. Conclusions BOS is not an infrequent occurrence in DCB PCI of small vessels and is correlated with vessel tortuosity, distal diffuse vessel disease, higher lesion complexity, and balloon diameter oversizing.