Revolutionizing Modern Percutaneous Coronary Intervention: Drug-Coated Balloons for Diabetics With Small Vessel Disease. A Narrative Review.

Diabetic patients with small-vessel coronary artery disease represent a challenging population in interventional cardiology. Conventional drug-eluting stents (DES) show limited efficacy due to enhanced neointimal proliferation, microvascular dysfunction, and impaired endothelial healing. This narrative review synthesizes contemporary evidence on drug-coated balloon (DCB) angioplasty efficacy, safety, and procedural strategies in diabetic small vessel disease (SVD). A comprehensive literature search of PubMed, Scopus, and Web of Science was conducted through October 2025, focusing on randomized controlled trials, meta-analyses, registries, and physiological studies comparing DCBs and DES in diabetic SVD. Recent trials (BELLO, Dissolve-SVD, BASKET-SMALL 2, PICCOLETO II) and meta-analyses indicate DCBs achieve non-inferior or superior angiographic outcomes versus DES in diabetic SVD, particularly regarding late lumen loss, restenosis, and vessel thrombosis. Procedural advantages include endothelial function preservation, reduced inflammation, and significantly shorter dual antiplatelet therapy duration-crucial for high-bleeding-risk diabetic populations. DCB angioplasty represents a promising "leave-nothing-behind" revascularization strategy for diabetic small vessels, combining efficacy with enhanced vascular healing and safety. Ongoing sirolimus-coated technology developments and future diabetes-focused trials are expected to refine its interventional role.