The DCB Playbook: Imaging, Vessel Prep, and Complex Coronary Decisions

Drug-coated balloons are creating new options in complex coronary intervention, but only when the lesion is prepared correctly.In this MurmurMD discussion, Dr. Nyal Borges and Dr. Pratik Sandesara walk through a practical, case-based approach to contemporary DCB use, focusing on ISR, calcific neoatherosclerosis, underexpanded stents, and bifurcation disease.The conversation starts with a severe LAD ISR case involving jailed diagonal branches and an under expanded stented segment. The operators discuss how imaging guides the diagnosis, why calcific atherosclerosis often requires atherectomy, when OPN and high-pressure balloons matter, and why DCB may be preferable to adding another layer of metal.They then move into a challenging LAD/diagonal bifurcation case, where the strategy becomes a hybrid approach: DES for the main LAD and DCB for the diagonal branch.Key topics include:• A practical framework for treating ISR• Differentiating tissue ISR, stent fracture, and mechanical under expansion• Why calcific atherosclerosis is so difficult to treat• Rotational atherectomy inside a stent• OPN and high-pressure balloon optimization• Imaging-guided vessel preparation before DCB• When to avoid adding another stent layer• DCB for jailed side branches and bifurcations• Cutting balloon strategy for de novo vessel prep• Using physiology to assess side branch stability after DCB• Why DES and DCB may be complementary rather than competitiveThis is a detailed, operator-level conversation on where DCB fits today — and why the success of DCB depends less on the balloon itself and more on diagnosis, imaging, and meticulous vessel preparation.🔔 Subscribe for more insights from interventional experts and real-world program builders.📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvAChapters:00:00 – Introduction: DCB in contemporary complex PCI00:51 – Case 1: Severe LAD ISR with jailed diagonal branches01:48 – A practical framework for image-guided ISR treatment02:25 – Calcific neoatherosclerosis vs neointimal hyperplasia03:20 – Mechanical underexpansion and calcium behind the stent04:20 – Why imaging matters before choosing a DCB strategy06:00 – DCB after vessel prep: when another stent layer is avoidable08:00 – Why this ISR lesion is high risk for recoil10:17 – Why OPN or IVL may not be enough in dense ISR calcium11:35 – Rotational atherectomy inside a stent15:09 – Long NC balloons, OPN, and confirming expansion16:26 – Wire strategy and practical OPN considerations18:00 – Post-treatment imaging and deciding whether to use DCB20:04 – Why DCB may be attractive in LAD ISR with jailed branches21:30 – What if you need to extend the stent?25:24 – Case 2: Complex LAD/diagonal bifurcation disease30:07 – IVUS assessment of LAD/diagonal anatomy31:09 – Hybrid strategy: LAD stent plus diagonal DCB31:46 – Cutting balloon and vessel prep for de novo DCB36:10 – Using pressure wire to assess side branch stability40:05 – When DES still makes sense in high-jeopardy anatomy42:00 – DCB timing in bifurcation workflows45:06 – Should you evaluate the side branch after provisional stenting?46:02 – Final angiogram and optimization47:10 – Future role of hybrid DES + DCB strategies#DCB #ComplexPCI #DrugCoatedBalloon#ISR #InStentRestenosis #CoronaryCalcium#BifurcationPCI #IVUS #RotationalAtherectomy#InterventionalCardiology #MurmurMD