A 63-year-old gentleman, an active chronic smoker with no known medicalillnesses but a strong family history of IHD, presented to the districthospital with sudden onset of chest pain in June 2024. He was normotensive,with unremarkable lung and cardiovascular examinations. The ECG showed STelevation in the inferior leads II, III, and aVF. He was treated with apharmaco-invasive strategy, in which he was successfully thrombolysed withStreptokinase and referred to our center for a coronary angiogram and angioplasty.

Troponin T was elevated, with an HbA1c of 6.9%(newly diagnosed diabetes mellitus), total cholesterol of 6.2 mmol/L, and LDLof 4.1 mmol/L. His creatinine was elevated, with an eGFR of 55 mL/min/1.73 m²,consistent with chronic kidney disease stage 2. The chest X-ray showed nocardiomegaly and clear lung fields. The echocardiogram reported preserved LVfunction, with an LVEF of 60%, no regional wall motion abnormalities, andnormal valves.

Diagnostic shots were taken using the radial artery approach. The leftmainstem was short and normal. There was severe disease (95%-99% stenosis) inthe ostial and proximal segments of the left circumflex artery, with ectaticsegments following the stenotic lesions. There was diffuse mild disease (30-40%stenosis) in the proximal and mid left anterior descending artery. The rightcoronary artery was non-dominant, with moderate disease (30-50% stenosis) inthe proximal and mid segments, and an ectatic segment in between.

The right radial artery approach was used, and theEBU 3.5 6FR guiding catheter was engaged into the left system. The lesion wascrossed without difficulty using a Run-through floppy guidewire to the distalLCX. The LAD was wired with a Sion Blue wire to provide additional support foradvancing the balloon to the LCX, as the left main was short. Initialpre-dilatation was performed with a small WEDGE NC balloon (2.5x15mm) at 12atm, followed by IVUS imaging for vessel sizing, lesion length, morphology, andassessment of the LAD and LM. IVUS revealed a vessel size of 5.0-5.5 mm at theectatic segment and 4.5-5.0 mm proximally, with fibrofatty plaque and a lipidpool at the proximal segment, along with superficial calcification. The LM andostial LAD were clean. Further preparation was performed with a WEDGE NCballoon (3.5x15mm) at a maximum pressure of 22 atm. The lesion was adequatelyprepared, with minimal recoil, no dissection, and good TIMI 3 flow. A decisionwas made to proceed with DCB to simplify the case, as the lesion was deemedsuitable for this approach. DCB with an AGENT 4.0x15mm balloon at 8 atm for 60seconds was used. The final result showed good TIMI 3 flow with no recoil ordissections.

Selected patients with de novo ostial lesions in anectatic coronary artery have favorable and comparable outcomes with the DCBapproach, provided they receive good vessel preparation with the aid ofintravascular imaging to prevent the long-term adverse effects associated withthe DES strategy, such as incomplete stent coverage, stent malapposition,adjacent vessel compromise, stent strut protrusion into the left main, ordissections, leading to more complex procedures and interventions.