DEB vs DES for Coronary Artery Lesions
Primary Recommendation
Drug-eluting stents (DES) should be your default choice for nearly all coronary lesions, with drug-eluting balloons (DEB) reserved specifically for in-stent restenosis after bare metal stent implantation or when additional stent layers are undesirable. 1
When to Choose DES (Default Strategy)
Strong Indications for DES Over Other Options
DES are recommended (Class I, Level A) for reduction of restenosis/re-occlusion if no contraindication to extended dual antiplatelet therapy (DAPT) exists 1. DES should be considered by default in nearly all clinical conditions and lesion subsets, except when concerns or contraindications for prolonged DAPT are present 1.
Specific scenarios where DES are strongly preferred: 1
- Left main disease
- Small vessels (<2.5mm diameter)
- In-stent restenosis (though DEB is also reasonable here)
- Bifurcation lesions
- Diabetes mellitus
- Long lesions
- Multiple lesions
- Saphenous vein grafts
DES Efficacy and Safety Profile
Second-generation DES (everolimus-eluting, zotarolimus-eluting) provide superior clinical outcomes compared to first-generation DES, with target lesion failure rates of 4.2% versus 6.8% at 1 year 1. The greatest risk of stent thrombosis occurs within the first year (0.7-2.0%), with late stent thrombosis rates of only 0.2-0.4% per year thereafter 1.
When to Choose DEB (Limited Indications)
Primary Indication: In-Stent Restenosis
Drug-eluting balloons should be considered (Class IIa, Level B) for treatment of in-stent restenosis after prior bare metal stent implantation 1, 2. This represents the strongest evidence-based indication for DEB use in coronary intervention.
The American College of Cardiology recommends DCBs as a reasonable alternative for in-stent restenosis treatment, particularly when additional stent layers are undesirable 2. In patients with in-stent restenosis who have an indication for revascularization, it is reasonable to perform repeat PCI with either a DES or DCB if anatomic factors are appropriate 2.
DEB for De Novo Lesions: Inferior to DES
For de novo coronary lesions, DEB (with or without bare metal stent) is clearly inferior to DES and should not be your first choice 3, 4. Meta-analyses demonstrate:
- Higher major adverse cardiac events (MACE): OR 1.94 (95% CI 1.24-3.05) for DEB+BMS versus DES 3
- Greater late lumen loss: +0.20mm more with DEB+BMS versus DES 3
- Increased target lesion revascularization: OR 2.53 (95% CI 1.36-4.72) for DEB+BMS versus DES 3
- Smaller minimum lumen diameter: -0.25mm with DEB+BMS versus DES 3
Potential DEB Consideration: Small Vessels with DAPT Contraindications
DEB may be considered in small vessel disease when contraindications to prolonged DAPT exist 5. The main approach should be a DEB-only strategy with only provisional bailout stenting 5. However, this remains a second-line option when DES cannot be used.
Critical Decision Algorithm
Step 1: Assess DAPT Tolerance
- Can the patient tolerate and comply with 12 months of DAPT? 1
- Is surgery requiring DAPT discontinuation anticipated within 12 months? 1
- Is there high bleeding risk? 1
- Are there financial or social barriers to DAPT compliance? 1
If YES to any above → Consider bare metal stent, NOT DEB 1
Step 2: Identify Lesion Type
- De novo lesion + DAPT tolerable → DES (default choice) 1, 2
- In-stent restenosis after BMS → DEB or DES (both reasonable) 1, 2
- In-stent restenosis with multiple stent layers → DEB preferred 2
Step 3: Confirm Technical Feasibility
- DES may be more difficult to implant due to polymer coating stiffness 1
- If DES cannot be successfully implanted → Use bare metal stent 1
Common Pitfalls to Avoid
Do Not Use DEB as First-Line for De Novo Lesions
Despite emerging interest, no Class I guideline recommendation exists for DEB use in de novo lesions 6. Current guidelines support DES as the standard approach 6. The performance of DEB lies between DES and bare metal stents, with a trend toward superiority over bare metal stents alone but clear inferiority to DES 7, 3.
Do Not Assume Class Effect
There is no class effect for DES—some have been shown to be harmful and others ineffective 1. Similarly, different drug-eluting balloons have varying efficacy, and you cannot assume all DEBs perform equally 5, 7.
Do Not Forget DAPT Duration Requirements
The greatest risk for DES thrombosis is early discontinuation of DAPT 1. Before implanting DES, you must discuss with the patient the need for and duration of DAPT and confirm their ability to comply 1. Minimum DAPT duration is 12 months for DES 1.
FDA Warning for Paclitaxel-Coated Devices
The FDA has issued warnings about possible increased long-term mortality with paclitaxel-coated balloons in peripheral applications, requiring careful patient selection and informed consent 2, 6. While this primarily applies to peripheral artery disease, it warrants consideration when using paclitaxel-coated DEBs in coronary applications.
Cost Considerations
DES is substantially more expensive than bare metal stents 1. However, cost-effectiveness analyses show reduction in total cost associated with DES because of avoidance of repeat procedures 1. When financial resources are limited, DES use may be rationed, with implantation only in patients at greatest risk for restenosis 1.