A 51-year-old Chinese man with no prior history of medical illness, active smoker for 20 pack years, presented with new onset of chest pain for 3 days. He complained of central chest pain, heaviness in nature with pain score 4/10 on arrival. Vital signs were stable, BP 102/68 mmHg, HR 64 bpm, SpO₂ 100% on room air. Lungs were clear, heart sound normal with no murmur. A 12-lead ECG showed sinus rhythm with widespread ST-segment depression over lead I, II, III, aVF, V3-V6 with ST elevation over aVR.

Creatine kinase level was elevated (753 u/L), renal function profile and serum electrolytes were within normal. Chest x-ray showed normal heart size with clear lung field. A transthoracic echocardiogram showed LVEF 50-55% with hypokinesia over inferolateral segment, normal chamber size. He was diagnosed with Non ST-segment Elevation Myocardial Infarction (NSTEMI) and underwent selective in-hospital coronary angiography and percutaneous coronary intervention (PCI) during the admission.

Coronary angiogram showed dominant RCA with findings of two vessel disease.Left main stem- normalLAD- proximal 20-30% mild stenosisLCX- mid chronic total occlusion 100%, collaterals from distal LAD to OM branch seenRCA- dominant, mid 99% stenosis

Percutaneous coronary intervention (PCI) was performed via transradial approach with 6 Fr sheath. Right coronary system was engaged with JR 4.0 6 Fr guiding catheter, RCA was wired down with Sion Blue wire till distal RCA. Mid RCA lesion site was predilated with NC Balloon 3.0x 15 mm, up to 24 atm, subsequently was stented with drug-eluting stent (DES)- Combo Plus 3.5x 38mm + Combo Plus 3.5x 13 mm. Good result was obtained, TIMI 3 flow.Then we proceed with PCI to CTO mid LCX. Left coronary system was engaged using EBU 3.0 6 Fr guiding catheter. CTO lesion was successfully crossed with Sion Blue wire till distal LCX. Lesion was prepared with Ryurei Balloon 2.0x 15 mm, up to 22 atm. Subsequently, Sirolimus DCB (Selution SLR 2.5x 40mm) was deployed at mid LCX, inflated up to 8 atm for 60 seconds. Good result was obtained, TIMI 3 flow, residual stenosis 20%, no dissection seen. He was angina free and discharged well the next day. We performed a re-look coronary angiogram after 3 months, which showed good positive remodeling with no restenosis over LCX. Patient remained asymptomatic.

This case showed good result on revascularization of de novo chronic total occlusion (CTO) lesion with drug coating balloon (DCB) only treatment. DCB has now been widely used for small vessel lesion (< 3.0 mm) and in-stent restenosis (ISR), however studies on DCB only treatment for CTO lesion are scarce. CTO lesions have higher risk of in-stent restenosis and stent thrombosis, which remains a challenge in interventional cardiology. The rationale of “stentless” strategy using DCB could potentially offer a solution. More clinical studies on DCB only treatment to CTO lesions are encouraged.