Clinical HistoryA 29-year-old Indian army man with no comorbidities presented to the AIIMS outpatient department with exertional angina of 2–3 weeks duration. He denied rest angina, palpitations, syncope, or prior cardiovascular history.

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Investigations

• ECG: Normal.
• Echocardiogram: Preserved left ventricular function, no regional wall motion abnormality.
• TMT: Positive for ischemia.
• CT Coronary Angiography: Proximal LAD lesion estimated at 25–40%

Given ongoing angina and positive stress test, invasive coronary angiography was performed.Coronary Angiography

• Left Main: Normal, bifurcating into LAD and LCx.
• LAD: Diffuse proximal plaque noted in LAO caudal projection before trifurcation; other projections appeared insignificant.
• LCx: Normal.
• RCA: Dominant, normal, TIMI III flow.

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Intravascular Ultrasound (IVUS)Pullback demonstrated diffuse fibrotic plaque just proximal to the trifurcation of LAD. Ostia of side branches were uninvolved.Management DecisionKey considerations included:

• Young age (29 years) with long expected lifespan.
• Lesion at proximal LAD trifurcation—stenting would require plaque-free landing zone, risking side branch jailing.
• Avoidance of long-term DAPT, stent thrombosis, and in-stent restenosis.
• Occupational demands as an active-duty army soldier.

After multidisciplinary discussion, stentless PCI with DCB angioplasty was planned.PCI Procedure

• Access: Right radial.
• Guide: 5F JL (Cordis) engaged in left main.
• Wire: Sion Blue advanced across the LAD lesion.
• Lesion Preparation:
• Semi-compliant 2.75 × 12 mm balloon dilatation at high pressure.
• Multiple cuts with 3.25 × 10 mm cutting balloon with gentle movements.
• Drug Delivery: Sirolimus-coated balloon (3.5 × 25 mm) inflated at high pressure for 60 seconds.
• Post-IVUS: MLA >6 mm² achieved at proximal LAD, with preserved side branches.
• Final Angiography: TIMI III flow, no dissection or recoil.

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In selected young patients with proximal LAD fibrotic plaques, IVUS-guided DCB angioplasty provides a viable stentless strategy, balancing long-term safety, occupational needs, and clinical efficacy. This case highlights the importance of intravascular imaging and individualized decision-making in modern PCI.Learning Points

• IVUS guidance is invaluable for characterizing fibrotic proximal LAD lesions and planning revascularization.
• DCB angioplasty offers a stentless PCI strategy, especially in young patients where long-term DAPT and stent-related issues are major concerns.
• Lesion preparation with cutting balloon before DCB enhances drug uptake and long-term outcomes.