Large eccentric plaque containing an echolucent zone by IVUS can be at increased risk for instability even though the lumen area is preserved at the time of initial study. Compensatory enlargement of vessel wall due to remodeling may contribute to the relatively small degree of stenosis by angiography.

Wider application of retrograde CTO PCI achieved a high rate of success in recanalisation with an acceptable rate of complications in Japan.

Objectives To evaluate the efficacy and safety of additional drug‐coated balloon (DCB) angioplasty after directional coronary atherectomy (DCA) for coronary bifurcation lesions. Background The optimal therapy for bifurcation lesions has not been established, even in the drug‐eluting stent era. DCA possibly prevents plaque and carina shift in bifurcation lesions by plaque debulking; however, the efficacy of combined DCA and DCB (DCA/DCB) for bifurcation lesions remains unclear. Methods This multicenter registry retrospectively recruited patients with bifurcation lesions who underwent DCA/DCB and follow‐up angiogram at 6–15 months. The primary endpoint was the 12‐month target vessel failure (TVF) rate. The secondary endpoints were procedure‐related major complications, major cardiovascular events at 12 months, restenosis at 12 months, target lesion revascularization (TLR) at 12 months, and target vessel revascularization (TVR) at 12 months. Results We enrolled 129 patients from 16 Japanese centers. One hundred and four lesions (80.6%) were located around the left main trunk bifurcations. No side branch compromise was found intraoperatively. Restenosis was observed in three patients (2.3%) at 12 months. TLR occurred in four patients (3.1%): 3 (2.3%) in the main vessel and 1 (0.8%) in the ostium of the side branch at 12 months. TVF incidence at 12 months was slightly higher in 14 patients (10.9%), and only two patients (1.6%) had symptomatic TVR. One patient (0.8%) had non‐target vessel‐related myocardial infarction. Conclusions Our data suggested that DCA/DCB provided good clinical outcomes and minimal side branch damage and could be an optimal non‐stent percutaneous coronary intervention strategy for bifurcation lesions.

Directional coronary atherectomy before DES implantation can possibly avoid complex stenting. This strategy may provide a good long-term outcome in patients with bifurcated lesions.

With IVUS guidance, aggressive DCA can safely achieve optimal angiographic results with low residual plaque mass, and this was associated with a low restenosis rate. Although adjunctive PTCA after optimal DCA improved the acute quantitative coronary angiography and quantitative coronary ultrasonography outcomes, its benefit was not maintained at six months.