Drug-coated balloons (DCBs) are increasingly used for de novo small vessel coronary disease (SVD). However, their efficacy may be influenced by plaque composition and vulnerability. This post hoc analysis of the PEPCAD China SVD study was published in EuroIntervention. It evaluated 266 lesions from 260 patients treated with either paclitaxel-coated balloons or plain old balloon angioplasty (POBA). Plaque vulnerability was assessed using a novel angiography-based radial wall strain (RWS) measurement, with a cutoff of maximum RWS (RWSmax ≥ 13%) defining vulnerable plaques.

At 9-month follow-up, lesions in the DCB group with high RWSmax had significantly higher in-segment late lumen loss (0.24 ± 0.53 mm vs 0.05 ± 0.16 mm), greater binary restenosis (14.9% vs 1.9%), and increased target lesion failure (10.2% vs 1.6%) compared with low RWSmax lesions. Among all high RWSmax lesions, outcomes did not differ significantly between DCB and POBA. This suggests that plaque vulnerability may attenuate the benefits of DCB therapy.

These findings indicate that RWS could serve as a predictive marker for angiographic and clinical outcomes, supporting individualized treatment strategies in small vessel coronary disease (SVD).