Great debate: drug-coated balloons are preferable to drug-eluting stents for coronary in-stent restenosis

Drug-coated balloons (DCBs) have emerged as a promising alternative to drug-eluting stents (DES) in percutaneous coronary interventions, particularly due to their 'leave nothing behind' approach. The present 'great debate' focuses on a comprehensive evaluation of the role of DCBs vs DES in the treatment of both in-stent restenosis (ISR) and de novocoronary artery disease. The PRO section emphasizes recent evidence supporting the efficacy of DCBs in small vessel disease and bifurcation lesions, the phenomenon of late lumen enlargement, and the importance of optimal lesion preparation. The CONTRA section outlines limitations of DCBs, especially in more complex lesion subsets, and highlights comparative long-term outcome data that currently favour DES in certain settings. The importance of adequate vessel preparation and novel technologies such as sirolimus-coated balloons and bioadaptor implants are also discussed. This great debate aims to inform future clinical decision-making and guide appropriate patient selection by presenting both the strengths and limitations of DCB-based strategies.