Drug-Coated Balloons Versus Drug-Eluting Stents Following Coronary Atherectomy in Severely Calcified Lesions: A Systematic Review and Meta-analysis.

Severely calcified coronary lesions are associated with increased risk of procedural complications, stent underexpansion, and restenosis. While atherectomy prepares vessels for treatment, drug-eluting stents (DES) are traditionally preferred over drug-coated balloons (DCB). DCBs offer a stent-free alternative that may improve vessel remodeling and may require shorter antiplatelet therapy. However, for severely calcified lesions, it remains unclear whether DCB or DES is more effective. Following PRISMA guidelines, a systematic search of PubMed, Embase, Web of Science, Scopus, and Cochrane Central identified randomized controlled trials and adjusted observational studies comparing DCB versus DES following atherectomy. The study endpoints included major adverse cardiovascular events (MACE), all-cause death, myocardial infarction (MI), target lesion revascularization (TLR), and major bleeding. Random-effects models were used to estimate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Eight observational studies comprising a pooled total of 1,968 patients (698 DCB and 1,270 DES) met the inclusion criteria. There was no statistically significant difference between the DCB and DES strategies regarding MACE (RR 1.12; 95% CI 0.85 to 1.47; I2 = 0%), MI (RR 1.11; 95% CI 0.40 to 3.04; I2 = 0%), major bleeding (RR 1.11; 95% CI 0.36 to 3.37; I2 = 0%), all-cause mortality (RR 1.18; 95% CI 0.78 to 1.79; I2 = 0%), or cardiac death (RR 0.67; 95% CI 0.34 to 1.32; I2 = 0%). However, DES was associated with a significantly lower risk of TLR in the pooled analysis (RR 1.82; 95% CI 1.14 to 2.91; I2 = 37.4%) and in the Kaplan-Meier curve (HR = 1.64, 95% Cl 1.11 to 2.42, p = 0.014). In conclusion, following mechanical atherectomy for calcified lesions, both DCB and DES demonstrate favorable MACE, mortality, and safety profiles. However, DES exhibits a consistent association with lower TLR. Given the observational nature and inherent selection biases of the data, these findings cannot establish definitive causal relationships and require caution.