Well, I can't say I was expecting that outcome. The results of the RIBS IV trial were presented at TCT 2014 last week, and I don't think I was the only surprised member of the Late-Breaking trials audience in Washington. The trial compared drug coated balloons (DCB) and drug-eluting stents (DES) for the treatment of in-stent restenosis (ISR) of a previously-implanted DES in the coronary arteries. The presenter noted that ISR from a DES is a fairly rare occurrence, but when it does occur, it's a huge challenge to treat.

If I were placing bets, I would have gone DCB all the way  ISR was meant to be the big value proposition for DCB in the coronary arteries. Plus, a stent in a stent just sounds crazy to me it's the sort of kitchen sink approach you wouldn't think would work in the tiny arteries of the heart.

Nevertheless, science prevailed over my reactionary opinion, and the trial unequivocally showed that DES were the better treatment. I couldn't help but wonder if this spells the end for DCB in the coronary arteries. If not ISR, what are DCB going to be used for? They certainly aren't going to compete against DES for de novo coronary lesions that treatment pathway is as solidified as they come. It might be time for DCB manufacturers to double down on their peripheral vascular programs, where it still seems like DCB have the most to gain.

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