Use of Drug-Coated Balloons in Chronic Total Occlusions: The ERCTO Registry

Chronic total coronary occlusions (CTO) are still a major challenge in interventional cardiology, affecting 16%–18% of patients with coronary artery disease. While drug-eluting stents (DES) have been a significant advancement in the treatment of CTOs, their use in long segments still presents limitations, such as a higher risk of restenosis, reocclusion, and alterations in vasomotor function.

Drug-coated balloons (DCB) have shown their efficacy in de novo lesions, particularly in small-caliber vessels. In the context of CTOs, DCBs constitute a promising alternative to reduce the length of implanted stents or, in certain cases, even avoid their placement altogether. However, the available evidence on their use in percutaneous transluminal coronary angioplasty (PTCA) for CTOs remains limited, based on observational studies with small cohorts (with encouraging results).

The aim of this retrospective, observational, non-randomized study was to analyze CTO-PTCA procedures included in the ERCTO (European Registry of Chronic Total Occlusions) Registry to assess the frequency of DCB use, the characteristics of treated lesions, and in-hospital outcomes.

Out of a total of 40,449 CTO-PTCA procedures performed in 184 centers, DCBs were used in 2506 cases (6.2%). Their use increased progressively, from 3.4% (n = 185 of 5498) in 2016 to 14.9% (n = 705 of 4722) in 2023. Mean patient age was 65.2 years and most patients in the cohort were men. The most frequently affected artery was the right coronary artery, followed by the left anterior descending artery. In 70% of cases, the J-CTO score was >2.

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In-hospital complications were infrequent. However, CTOs treated with DCB showed a significantly lower rate of cardiac tamponade (0.1% [n = 2 of 2506] vs. 0.4% [n = 169 of 37,943]; p = 0.006) compared with the rest of the patients. After propensity score adjustment, DCB use was associated with a shorter total stent length (44.2±36.9 mm [95% confidence interval (CI): 42.7–45.7] vs. 58.1±35.9 mm [95% CI: 56.7–59.5]; p <0.001) and a reduction in the volume of contrast administered (202.4±109.8 mL [95% CI: 198.1–206.7] vs. 211.6±123 mL [95% CI: 206.8–216.4]; p = 0.005).

Conclusion

In this large-cohort observational study from the ERCTO Registry, there was a progressive increase in the use of DCBs in CTO-PTCA procedures. Their use allowed for a reduction in implanted stent length, decreased the volume of contrast administered, and was associated with a lower incidence of cardiac tamponade.

Original Title: Drug-Coated Balloons in the European Registry of Chronic Total Occlusion The ERCTO Registry.

Reference: Niccolò Ciardetti, MD et al JACC Cardiovasc Interv. 2025;18:2209–2221.