Stentless percutaneous coronary intervention with directional coronary atherectomy and drug-coated balloon angioplasty in worsening angina patients with metal allergies

Metal allergy is a concern in percutaneous coronary intervention (PCI) with stent implantation because of its potential association with poor cardiovascular outcomes, such as stent thrombosis and recurrent in-stent restenosis requiring revascularization. Although stentless PCI with drug-coated balloon (DCB) angioplasty is theoretically useful for patients with metal allergies, DCB angioplasty alone for huge plaques in large vessels may yield inadequate luminal enlargement and coronary deep dissection, leading to insufficient results. Directional coronary atherectomy (DCA) is effective to reduce plaque volume. However, the efficacy of DCA followed by DCB (DCA/DCB) angioplasty in patients with metal allergies has never been described. We present two cases wherein stentless PCI with DCA/DCB angioplasty was an alternative revascularization strategy for patients with metal allergy and concomitant worsening angina pectoris involving proximal left anterior descending artery stenoses. Preoperative evaluation using coronary computed tomography angiography in Case 1 and intravascular ultrasound in Case 2 was useful to determine the possible use of the DCA/DCB procedure for huge plaques in large vessels. LEARNING OBJECTIVE: Revascularization for patients with metal allergy with worsening angina pectoris due to stenoses of the proximal main arteries is often challenging because of the necessity to avoid stent implantation. As stentless percutaneous coronary intervention (PCI) is theoretically useful in such settings, PCI with directional coronary atherectomy (DCA)/drug-coated balloon angioplasty can be one of the treatable strategies. Preoperative evaluation of plaque morphology for the suitability of DCA procedure is important.