Drug-eluting Balloon Angioplasty as a Bridge to Early Liver Transplantation in Recipients with Coronary Artery Disease: A Case Series.

BACKGROUND

Coronary artery disease (CAD) is increasingly recognized among patients with end-stage liver disease (ESLD), particularly in the context of metabolic dysfunction-associated steatotic liver disease (MASLD). Management of CAD in liver transplant candidates is challenging due to the competing risks of ischemic events and perioperative bleeding, especially when dual antiplatelet therapy (DAPT) is required after coronary stenting. Drug-eluting balloon (DEB) angioplasty offers a "leave-nothing-behind" approach that may reduce the need for prolonged DAPT, providing a potential bridge strategy to early liver transplantation.

METHODS

We describe a series of four patients with ESLD and significant CAD who underwent DEB-only percutaneous coronary intervention (PCI) prior to living donor liver transplantation (LDLT). All patients were considered high-risk for standard drug-eluting stent (DES) implantation owing to urgent transplant indication or high-grade portal hypertension with varices. The DAPT duration was minimized (10-14 days) in all patients before transplantation.

RESULTS

All four patients underwent successful DEB angioplasty without stent placement-three involving the left anterior descending artery and one involving multivessel disease. None experienced perioperative myocardial ischemia, cardiac events, or major bleeding. Liver transplantation proceeded within 2 weeks after PCI in all cases. Postoperative outcomes were favorable, with no cardiac or graft-related complications during early follow-up (up to 3 months).

CONCLUSION

The DEB-only PCI may represent a feasible bridge strategy for selected liver transplant candidates with significant CAD when conventional DES-based revascularization poses excessive bleeding or delay risks. This approach allows safe shortening of DAPT before urgent liver transplantation.