Abstract
Although drug-coated balloons (DCBs) are increasingly used in acute coronary syndrome (ACS), evidence regarding mid-term clinical outcomes after DCB angioplasty remains limited. Real-world data evaluating whether intravascular ultrasound (IVUS)-guided lesion preparation is associated with improved outcomes compared with angiography-guided intervention are scarce, particularly in patients with complex coronary lesions. This study compares clinical outcomes associated with IVUS versus coronary angiography (CAG) guidance for DCB angioplasty in patients with ACS, focusing on major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) within the prespecified 24-month observation window. This retrospective study included 229 patients with ACS treated with DCB angioplasty between October 2017 and June 2025. Patients were categorized into IVUS-guided (n = 122) and CAG-guided (n = 107) groups according to the imaging strategy used during the procedure. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline confounders. The primary endpoints were MACE and NACE occurring within the prespecified 24-month observation window after DCB angioplasty. Secondary outcomes included individual clinical events, procedural characteristics, length of stay, and biochemical parameters assessed at predefined follow-up time points. After IPTW adjustment, baseline characteristics were balanced between groups. Procedural parameters, including DCB diameter, number of DCBs deployed, and bailout stenting rate, were comparable (all
P
> .05). Within the prespecified 24-month observation window, MACE occurred less frequently in the IVUS group than in the CAG group (8.2% vs 17.8%; IPTW
P
= .038). Major bleeding was also lower in the IVUS group (1.6% vs 11.2%; IPTW
P
= .015), contributing to a lower incidence of NACE (9.8% vs 26.2%; IPTW
P
= .001). IVUS guidance was additionally associated with a shorter hospital stay (4.2 vs 5.8 days;
P
< .001), while biochemical parameters remained comparable during follow-up. In patients with ACS treated with DCB, IVUS‑guided angioplasty was associated with significantly lower MACE and improved NACE outcomes during follow-up compared with angiography‑guided therapy alone. This benefit was largely attributable to an improved safety profile (e.g., fewer bleeding events). The associations remained consistent across subgroups, suggesting that IVUS‑guided lesion preparation may offer clinical value in this population and warrants further investigation.