Drug-coated Balloons in the Treatment of Coronary Artery Disease: Results from the Drug Eluting Technologies Evaluation & Current Trends (DETECT) Survey

Abstract

Aims:

Drug-coated balloons (DCBs) are increasingly used in percutaneous coronary intervention (PCI) but there are limited data available on practice patterns. Our survey evaluated the views of interventional cardiologists with respect to various clinical and technical aspects of DCB angioplasty.

Methods:

A voluntary, online survey involving 13 questions – the Drug Eluting Technologies Evaluation & Current Trends (DETECT) Clinical Practice Survey – was conducted in two waves: a census of Irish interventional cardiologists in April 2025 and an onsite survey at the EuroPCR Congress in May 2025. The question topics included indications for DCB use, device selection factors, dual antiplatelet therapy (DAPT) duration and intravascular imaging use. Respondent characteristics were recorded.

Results:

A total of 136 respondents (126 consultants, 10 fellows) from 39 countries (60 Ireland, 76 EuroPCR) participated in the survey. The survey revealed that most consider a DCB for in-stent restenosis (ISR; 99%), small vessel disease (95%) and bifurcation lesions (77%). A lower proportion consider a DCB strategy in chronic total occlusion (29%), any vessel size (21%) or acute coronary syndrome (17%). No differences by level of interventional experience (>10 years, <10 years or fellow) (χ²=10.35; p=0.11). DCB comprised 1–10% of annual PCI for half of the respondents (55%); most respondents (82%) anticipated an increase in their use. Paclitaxel DCBs were widely available (93%) but sirolimus DCBs less so (55%). DAPT duration post-DCB in chronic coronary syndromes was commonly prescribed for 3 months (43%) or 6 months (33%). Most use intravascular imaging for 21–50% of their DCB cases.

Conclusion:

This survey suggests that DCBs have been widely adopted by interventional cardiologists for the treatment of ISR and small vessel disease, with anticipated growth in the next 2 years.

Drug-coated balloons (DCBs) are standard angioplasty balloon catheters with a matrix coating applied to the surface of the balloon. Their use is well established for the treatment of coronary in-stent restenosis (ISR). In recent years, several studies have investigated the use of DCBs in other settings, including small-vessel and large-vessel de novo lesions, bifurcations, chronic total occlusion (CTO) and in patients presenting with acute coronary syndrome (ACS).1–6

The perception of the global interventional community regarding the adoption of DCB technology has not been fully defined. There are clear geographic variations in the clinical use of DCB angioplasty in the treatment of coronary artery disease, with differing levels of associated cost and indications for reimbursement for DCB balloon catheters. Regulatory approval conditions also differ across jurisdictions. In Europe, the use of DCBs for ISR has been supported for several years in guidelines and consensus documents.7 However, the 2024 European Society of Cardiology (ESC) guidelines for the management of chronic coronary syndromes (CCS) gave a preferential recommendation for the use of repeat drug-eluting stent (DES) over DCB for DES-ISR due to lower target-lesion revascularisation in meta-analyses, while recognising scenarios that favour a DCB approach (multiple stent layers, underexpansion, major bifurcations, high bleeding risk).8 In the US, the AGENT DCB (Boston Scientific) became the first Food and Drug Administration (FDA)-approved coronary DCB for ISR in March 2024, aligning US practice more closely with Europe’s decade-long experience and potentially accelerating adoption.9

Against this background, we surveyed interventional cardiologists to characterise their perceptions of contemporary coronary DCB indications, current procedural practices and their predicted future trajectory of DCB use. We included a mixed sample comprising an Irish interventional cardiology census and a cohort of onsite attendees at the EuroPCR 2025 Congress (Paris; 20–23 May) to give breadth to our survey. We conducted the Drug Eluting Technologies Evaluation & Current Trends (DETECT) study to evaluate their opinions regarding the clinical and technical aspects of DCB angioplasty, their preferences regarding duration of antiplatelet therapy post DCB angioplasty in CCS patients and whether intravascular imaging (IVI) use differed with DCB angioplasty compared with IVI use during DES percutaneous coronary intervention (PCI).

Methods

We conducted a cross-sectional, voluntary online survey including 13 questions. The questionnaire was pilot-tested by three investigators for clarity; the full survey is provided in the Supplementary Material. The survey was conducted using the online Microsoft Forms platform.

Interventional cardiologists were invited to participate by email or by direct in-person invitation during the EuroPCR 2025 Congress. Two separate strategies were deployed targeting two different participant groups. Initially, an email invite was sent to every practising interventional cardiologist in Ireland during April 2025. Every effort was made to formulate a complete list of all practising interventional cardiologists using hospital directories, the Cardiovascular Research Institute (CVRI) mailing list and assistance from the Irish Cardiac Society. Following this, in May 2025, the survey was repeated at the EuroPCR 2025 Congress by direct invitation to attendees at two separate DCB sessions taking place during the congress.

Respondent characteristics were broken down into six groupings: years of experience, hospital or country of practice, total number of PCI cases performed per year, total number of DCB cases they performed per year, use of IVI and whether they worked in a 24-hour primary PCI centre.

Drug-coated Balloon Usage Patterns

The primary outcome of interest was the proportion of respondents who would consider the following indications for DCB angioplasty: ISR, small-vessel de novo disease (SVD), bifurcation lesions, CTO, any vessel size or patients presenting with an ACS.

Secondary Outcomes

There were five secondary outcomes. First was the number (%) of participants who had paclitaxel, sirolimus or both types of DCB catheter devices available for them to use at their institution. Second was the ranking of factors in order of importance from one to six when making their decision to choose a particular DCB device. The factors were: antiproliferative drug preference, i.e. paclitaxel or limus-containing compound; clinical evidence available for the DCB; availability of the DCB in their cath lab; cost of the DCB device; size matrix available (e.g. 2–5 mm diameter, 10–30 mm length); and deliverability of the DCB device. Third was the proportion (%) of PCI cases in which the respondents use IVI in their total routine DES-based PCI cases and in their total DCB angioplasty cases. Fourth was the proportion (%) of respondents who generally prescribe dual antiplatelet therapy (DAPT) for 1 month, 3 months, 6 months or 12 months, in the setting of patients presenting with CCS receiving DCB angioplasty. Fifth was the proportion (%) of respondents who believed there was a ‘class effect’ in relation to performing DCB angioplasty with different DCB catheter devices.

Statistics

The statistical analyses were largely descriptive. Categorical variables were summarised as n (%). This was a quantitative survey with categorical variables, so comparisons were carried out using the χ^² test of independence to assess for variations across the two cohorts surveyed: the Irish census and the EuroPCR cohort. Analysis was performed using GraphPad Prism for Microsoft Windows version 10.1.2 (GraphPad Software).

Bias

To reduce potential sources of bias, the survey instrument was developed following best practices for questionnaire design. Items were pre-tested to ensure clarity and neutrality. Responses were collected anonymously to limit social desirability bias. Non-response was addressed through repeated contact attempts. While these measures were implemented to mitigate bias, residual confounding cannot be excluded and is acknowledged as a limitation.

Ethics

The survey was anonymous, voluntary and met the criteria for institutional review board exemption so no ethical approval was required. Participation implied informed consent.

Data Availability

Most of the data supporting the findings of this study are available in the article or Supplementary Material. Individual respondent data are available from the corresponding author on reasonable request. There were no missing data because it was compulsory for each question to be answered in order for the survey to be completed. Raw data are available on reasonable request.

Results

A total of 136 respondents (126 consultants, 10 fellows) from 39 countries participated in the DETECT study; we analysed 60 respondents from Ireland (estimated 58% national response), and 76 from an international cohort attending the EuroPCR 2025 Congress. This included respondents from Europe excluding Ireland (36), Asia (22), North America (9), South America (4), Australia and New Zealand (4) and Africa (1).

A breakdown of the respondent characteristics is provided in Table 1, with a breakdown of the countries represented demonstrated in Figure 1.

Table 1: Respondent Characteristics.

Respondent Characteristics	Combined (Total = 136), n (%)	Ireland (Total = 60), n (%)	EuroPCR Congress (Total = 76), n (%)	Difference p-value*
Professional Status
Interventional cardiologist with >10 years’ experience	76 (56%)	32 (53%)	44 (58%)	0.56
Interventional cardiologist with <10 years’ experience	50 (37%)	22 (37%)	28 (37%)
Interventional cardiologist in training (interventional fellow)	10 (7%)	6 (10%)	4 (5%)
Region
Ireland	60 (44%)
Europe (excluding Ireland)	36 (26%)
Asia	22 (16%)
North America	9 (7%)
South America	4 (3%)
Australia and New Zealand	4 (3%)
Africa	1 (1%)
Primary PCI Centre Status
24-hour primary PCI centre	101 (74%)	29 (49%)	72 (95%)	<0.01
In-hours only primary PCI	35 (26%)	30 (51%)	4 (5%)
Annual PCI Volume per Respondent
1–50 PCI cases	5 (4%)	2 (3%)	3 (4%)	0.11
51–100 PCI cases	22 (16%)	12 (20%)	10 (13%)
101–200 PCI cases	47 (35%)	24 (40%)	23 (30%)
201–500 PCI cases	51 (38%)	21 (35%)	30 (39%)
>500 PCI cases	11 (8%)	1 (2%)	10 (13%)
Rate of Intravascular Imaging Use During PCI per Respondent
0% of PCI cases	5 (4%)	1 (2%)	4 (5%)	<0.01
1–10% of PCI cases	33 (24%)	8 (13%)	25 (33%)
11–20% of PCI cases	31 (23%)	9 (15%)	22 (29%)
21–50% of PCI cases	28 (21%)	13 (22%)	15 (20%)
>50% of PCI cases	39 (29%)	29 (48%)	10 (13%)

*χ² test of independence, two-sided p<0.05 considered as statistically significant. PCI = percutaneous coronary intervention.

Figure 1: Countries Represented in the DETECT Survey.

Ireland (n=6), Spain (n=10), India (n=9), Mexico (n=7), Germany (n=5), Japan (n=3), Paraguay (n=3), Switzerland (n=3), Australia (n=2), Italy (n=2), New Zealand (n=2), Slovakia (n=2), South Korea (n=2), Argentina (n=1), Bangladesh (n=1), Belgium (n=1), Canada (n=1), Croatia (n=1), Czech Republic (n=1), Estonia (n=1), Finland (n=1), France (n=1), Greece (n=1), Hong Kong (n=1), Hungary (n=1), Iran (n=1), Israel (n=1), Kosovo (n=1), Lithuania (n=1), the Netherlands (n=1), Oman (n=1), Philippines (n=1), Poland (n=1), Portugal (n=1), South Africa (n=1), Taiwan (n=1), Thailand (n=1), Turkey (n=1), US (n=1).

Regarding the primary outcome, the majority of respondents agreed that a DCB strategy was suitable for the treatment of ISR (99%), small vessel disease (95%) and bifurcation lesions (small or main branch; 77%). A smaller proportion of respondents felt CTO (29%), de novo any vessel size (21%) or presentation with ACS (17%) were indications for which they would consider a DCB-based PCI strategy.

A full breakdown of the survey results is demonstrated in Table 2 and Figure 2. Regarding the secondary outcomes, clinical evidence being available for the DCB device was the factor that most influenced practitioners’ decisions when choosing a particular DCB, followed by local availability, drug preference, cost, size matrix being available and deliverability of the device.

Table 2: Main Results of the DETECT Survey.

DETECT Survey Results	Combined (Total = 136), n (%)	Ireland (Total = 60), n (%)	EuroPCR Congress (Total = 76), n (%)	Difference p-value*
DCB Angioplasty Cases per Respondent
0% of total PCI cases	0	0	0	0.10
1–10% of total PCI cases	75 (55%)	34 (57%)	41 (54%)
11–20% of total PCI cases	42 (31%)	22 (37%)	20 (26%)
21–50% of total PCI cases	15 (11%)	4 (7%)	11 (14%)
>50% of total PCI cases	4 (3%)	0	4 (5%)
Rate of Intravascular Imaging Use During DCB Angioplasty per Respondent
0% of DCB cases	12 (9%)	5 (8%)	7 (9%)	0.23
1–10% of DCB cases	27 (20%)	7 (12%)	20 (26%)
11–20% of DCB cases	24 (18%)	10 (17%)	14 (18%)
21–50% of DCB cases	24 (18%)	12 (20%)	12 (16%)
>50% of DCB cases	49 (36%)	26 (43%)	23 (30%)
Indications Respondents Would Consider a DCB Strategy
ISR	134 (99%)	59 (98%)	75 (99%)	0.46
Small vessel disease	129 (95%)	55 (92%)	74 (98%)
Bifurcation lesion (SB or MV)	105 (77%)	42 (70%)	63 (83%)
De novo (any vessel size)	28 (21%)	8 (13%)	20 (26%)
CTO	40 (29%)	18 (30%)	22 (29%)
ACS (including STEMI)	23 (17%)	10 (17%)	13 (17%)
Ranking of factors influencing choice of DCB (1st as most important through 6th as least important)
Clinical evidence for the DCB	1st	2nd	1st	0.76
Local availability (i.e. on shelf)	2nd	1st	2nd
Drug preference, i.e. paclitaxel or sirolimus	3rd	3rd	3rd
Size matrix available	4th	4th	5th
Cost	5th	6th	4th
Deliverability of the device	6th	5th	6th
DCB Type Currently Available at Respondents’ Institution
Paclitaxel-coated balloon	61 (45%)	23 (38%)	38 (50%)	0.32
Sirolimus-coated balloon	10 (7%)	4 (7%)	6 (8%)
Both types	65 (48%)	33 (55%)	32 (42%)
DAPT Duration Prescribed in CCS
1 month	25 (18%)	7 (12%)	18 (24%)	0.31
3 months	59 (43%)	27 (45%)	32 (42%)
6 months	45 (33%)	23 (38%)	22 (29%)
12 months	7 (5%)	3 (5%)	4 (5%)
Whether Respondents Believe There is a ‘Class Effect’ Across Different DCB Devices
There is no class effect	69 (51%)	17 (28%)	52 (68%)	<0.01
There is a class effect	67 (49%)	43 (72%)	24 (32%)
Whether respondents Think Their Rates of DCB as a Proportion of Their PCI Will Rise or Fall
Rates of DCB angioplasty will rise in the next 2 years	111 (82%)	43 (72%)	68 (89%)	0.01
No expected change in their DCB angioplasty rates	25 (18%)	17 (28%)	8 (11%)
Rates of DCB angioplasty will fall in the next 2 years	0	0	0

*χ² test of independence, two-sided p<0.05 considered as statistically significant. ACS = acute coronary syndrome; CCS = chronic coronary syndrome; CTO = chronic total occlusion; DAPT = dual antiplatelet therapy; DCB = drug-coated balloon; ISR = in-stent restenosis; MV = main vessel; PCI = percutaneous coronary intervention; SB = side branch; STEMI = ST-elevation MI.

Figure 2: Main Results of the DETECT Survey.

ACS = acute coronary syndrome; CCS = chronic coronary syndrome; CTO = chronic total occlusion; DAPT = dual antiplatelet therapy; DCB = drug-coated balloon; ISR = in-stent restenosis; PCI = percutaneous coronary intervention; SVD = small-vessel disease.

For the majority of respondents (55%), DCB angioplasty constituted 1–10% of their total PCI cases. Across the three levels of operator experience (>10 years, <10 years or fellow in training), no statistically significant differences in reported DCB usage percentages were detected (χ^²=10.3; degrees of freedom [d.f.]=6; p=0.11). The majority of respondents (82%) predicted that their use of DCBs will rise in the next 2 years. Most respondents, 126 (93%), had paclitaxel-coated balloons available in their institution. A lower proportion of respondents (55%) reported the availability of sirolimus-coated balloons.

Overall, there was an equal spread among respondents about whether there is a ‘class effect’ across different DCB devices; however, the cohorts themselves differed in this respect, with 52 (68%) respondents saying there was no class effect in the EuroPCR group versus 17 (28%) respondents in the Ireland cohort (p<0.01).

Intravascular Imaging

IVI usage was analysed as an ordinal outcome (0%, 1–10%, 11–20%, 21–50%, >50%). The majority of respondents reported using IVI in 21–50% of their PCI cases. We then compared the distribution of IVI usage across respondents based in Ireland with those from the international (EuroPCR) cohort. Compared with international respondents, interventionists in Ireland reported higher use of IVI; this difference was statistically significant across categories (χ²=20.98; d.f.=4; p<0.01).

With respect to IVI use in DCB angioplasty, the majority of respondents reported using IVI in 21–50% of their DCB cases. We did not detect a difference in the percentage of cases using IVI during DCB angioplasty between the Ireland and EuroPCR cohort (χ^²=4.35; d.f.=4; p=0.36).

Duration of Dual Antiplatelet Therapy

The most common reported DAPT duration for CCS patients treated with DCB angioplasty was 3 months (43%), followed by 6 months (33%). The overall distribution of DAPT durations did not differ significantly between the Ireland and EuroPCR cohorts (χ^²=3.41; d.f.=3; p=0.31).

Discussion

This international survey provides a contemporary snapshot of DCB use among interventional cardiologists. The results of the survey demonstrate that there is broad adoption for the use of DCBs in the treatment of ISR and SVD, with growing interest in bifurcation lesions. These findings align with longstanding European consensus and guideline recommendations that support DCBs for ISR and select de novo lesions, particularly in small vessels where stent implantation may be undesirable.¹ Interestingly, recent meta-analyses of randomised controlled trials comparing DCB with DES in de novo disease have demonstrated comparable outcomes in terms of major adverse cardiovascular events.10,11

Conversely, there were lower degrees of support for the use of DCBs in the treatment of ACS (17%) and de novo lesions of any size (21%), perhaps reflecting the lack of robust randomised evidence supporting DCBs as an alternative to DES in these settings.

Projected adoption trends were striking: over 80% of respondents anticipate that they will increasingly use DCBs in clinical practice in the next 2 years. This optimism likely reflects recent regulatory milestones, including the first FDA approval of a coronary DCB (AGENT) for ISR in 2024, and expanded CE indications for the Prevail DCB (Medtronic) in 2025 to include bifurcation, multivessel disease, ACS and diabetes.3,4

Approximately one-third of respondents reported IVI use in more than 50% of DCB angioplasty cases, with the remainder using IVI in fewer than half of their cases. IVI utilisation patterns were comparable for DES-based PCI. Imaging-guided lesion preparation is critical for DCB success, particularly in complex subsets such as bifurcations and heavily calcified lesions. Future research should explore whether systematic imaging improves outcomes and reduces geographic variability in DCB performance.

A notable finding of our survey is that 99% of respondents considered DCB therapy suitable for ISR, which contrasts with the 2024 ESC guidelines for CCS that express a preference for repeat DES implantation in most cases of ISR. Several factors may contribute to this divergence. First, many operators may perceive DCBs as a pragmatic and clinically effective solution, especially in complex ISR patterns where adding a third metal layer is undesirable. Second, operator familiarity and training likely influence procedural preference: interventional cardiologists who regularly use DCBs – and who constituted a large proportion of respondents in our survey – may have greater confidence in their performance than is reflected in formal guideline weighting. Finally, guideline recommendations may lag behind emerging data or evolving practice patterns. Although the ESC guidelines currently prioritise DES for ISR, real-world contemporary practice may be shifting toward broader DCB adoption. It would have been informative to ask respondents directly about their preferred treatment strategy for ISR, as this would have provided additional context for interpreting our findings. Overall, the strong endorsement of DCBs among respondents highlights on-going differences between evidence-based recommendations and practical, operator-driven decision-making in ISR management.

A further noteworthy finding from our survey is the marked difference between the Irish and EuroPCR cohorts regarding the perceived presence of a ‘class effect’ among DCB devices. While the overall respondent pool was evenly divided on this question, the two groups diverged significantly: 68% of EuroPCR respondents believed there was no class effect, compared with only 28% of the Irish cohort (p<0.01). This discrepancy probably reflects differences in exposure, experience and interpretation of the available evidence between the two populations. The EuroPCR cohort – comprising an international group of operators, some of whom are likely actively engaged in DCB research and development – may be more familiar with the mechanistic differences across contemporary DCB platforms and thus more inclined to view them differently. In contrast, the Irish cohort may be more influenced by local practice patterns, device availability or a perceived lack of difference in efficacy among specific DCB technologies. These contrasting perspectives underscore the on-going uncertainty within the field regarding whether DCBs can be considered a homogeneous class or whether individual device characteristics meaningfully influence clinical outcomes. The divergence also highlights the need for continued head-to-head comparative studies and clearer guidance to reconcile operator perceptions with emerging evidence.

Our survey also identified variability in DAPT duration after DCB-only PCI in CCS patients. While consensus documents often recommend approximately 4 weeks of DAPT following DCB-only treatment in de novo small vessels, most respondents favoured 3 months (44%) or 6 months (32%) durations of DAPT.⁵ This divergence suggests opportunities for harmonisation and underscores the need for prospective studies to define optimal antiplatelet strategies post DCB PCI, tailored to lesion type and patient risk.

Our findings emphasise the need for randomised trials in de novo lesions, bifurcations and ACS to strengthen the clinical evidence for these expanded indications. Economic evaluations to assess cost-effectiveness and reimbursement impact on broad adoption of DCB angioplasty are also warranted. As the regulatory landscape evolves, and sirolimus-coated balloons gain traction, practice patterns will likely shift further. Harmonising clinical protocols and generating high-quality evidence remain essential to optimise patient outcomes and fully realise the potential of DCB technology.

Study Limitations

This survey has several limitations. First, the generalisability of the findings to an international perspective is limited by the relatively small sample size and the results may not necessarily be representative of the wider international cardiology community. However, there was high participation across the Irish interventional cardiology community, so the results have a high likelihood of being representative of this specific community. Non-response bias is also possible.

Low participation rates are common in international surveys, particularly in those targeting professionals at an advanced career stage. We cannot exclude selection bias towards respondents positively predisposed to the use of DCB angioplasty, because physicians with greater interest and personal involvement in these techniques may be more likely to participate in the survey. The second wave of data collection at EuroPCR took place during two DCB-focused sessions. This setting likely introduced a bias toward respondents already engaged with or interested in DCB therapy, so the findings may not fully reflect the perspectives of the wider interventional cardiology community.

The survey provides a snapshot of practice patterns and operator perceptions and cannot reflect actual use or address changes over time. We cannot exclude the possibility that perceptions regarding the use of DCB for de novo coronary artery disease may have changed following the presentation of a large study shortly after the survey was completed, the SELUTION DeNovo study (NCT04859985), which could have shifted respondent perceptions. We did not link responses to hospital or operator reimbursement and approval status, which may drive availability and adoption.

Conclusion

This survey suggests that DCBs have been widely adopted by interventional cardiologists for the treatment of ISR and small vessel disease, with anticipated growth in the next 2 years.

Clinical Perspective

• Drug-coated balloons (DCBs) were widely adopted for in-stent restenosis (99%), small-vessel disease (95%) and bifurcation lesions (77%) among interventional cardiologists who responded to our survey; most operators anticipate increasing their DCB use within the next 2 years.

• Randomised controlled trials demonstrating positive outcomes for DCB angioplasty in emerging indications, such as large vessels, chronic total occlusions and acute coronary syndromes, are required before widespread adoption.

• Further studies to guide lesion preparation strategies and dual antiplatelet therapy durations with DCB percutaneous coronary intervention may be beneficial to reduce variability in clinical practice and optimise outcomes.

Funding Statement

This research was supported in part by an unrestricted educational grant from Cordis.

Data availability:

Most of the data supporting the findings of this study are available in the article or supplement. Individual respondent data (raw data) are available from the corresponding author on reasonable request.