Intravascular brachytherapy versus drug-coated balloons for in-stent restenosis: A two-center two-strategy comparison

Background: In-stent restenosis remains a persistent challenge in interventional cardiology. While both intravascular brachytherapy (IVB) and drug-coated balloons (DCB) have been used to treat this condition, their comparative effectiveness has never been evaluated. Objectives: To compare the efficacy and safety of IVB versus DCB for the treatment of in-stent restenosis. Methods: This dual-center study compared 2-year outcomes between patients treated with IVB and DCB. Propensity score matching was performed for age, sex, vessel size, and ejection fraction. Primary outcomes included all-cause mortality and target lesion revascularization (TLR). Results: DCB treatment was associated with shorter procedure times median 52 IQR[40.0,68.0] vs 72 IQR[60.0,92.0] min, p < 0.01) and reduced contrast use (median 121 IQR[76.50,155.0] vs 140 IQR[100.0,200.0] mL, p = 0.03). In the propensity-matched cohort, MACE rates were similar (43.3 % vs 47.7 %, p = 0.55). DCB treatment demonstrated significantly lower TLR rates compared to IVB (4.4 % vs 18.9 %, p < 0.01) and reduced target vessel myocardial infarctions (3.3 % vs 13.3 %, p = 0.02). All-cause mortality (14.4 % vs 7.8 %, p = 0.15) and cardiac death rates (6.7 % vs 4.4 %, p = 0.52) were similar between groups. Conclusions: In this first-ever comparison with 2-year follow-up, DCB was associated with similar MACE rates compared to IVB but demonstrated lower TLR rates. All-cause mortality and cardiac death rates were comparable. These findings may suggest that DCB offers superior efficacy for ISR treatment, though careful patient selection remains important when considering treatment modalities.