Imaging inside the artery and pressure wires help decide which narrowings need a stent and check that each stent has opened fully. Drug-coated balloons can treat selected blockages without leaving metal behind, and lithotripsy and atherectomy prepare arteries hardened by calcium. Medicines and risk-factor control are still the foundation of treatment.
Four advances in angioplasty
This page covers imaging, pressure wires, drug-coated balloons and calcium treatment. For what an angiogram and stent are, see Heart procedures explained: angiograms, stents and advanced techniques; for preparing and recovery, see Coronary angiogram and stent: what to expect.
The stent is still central to treatment, but how a blockage is assessed, prepared and treated has changed.
Imaging inside the artery
IVUS and OCT show what an angiogram cannot: wall thickness, calcium and how well a stent has expanded.
Drug-coated balloons
Treat selected blockages with medicine, with no permanent metal implant left behind.
Calcium tools
Lithotripsy and atherectomy crack or sand down hardened plaque so stents can open fully.
Modern stents and shorter DAPT
Thinner stents heal well, and many patients now take two blood-thinning tablets for fewer months.
Looking inside the artery with IVUS and OCT
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) use tiny imaging probes, about the width of a few hairs, passed into the artery on a thin wire. They show the artery from the inside, in cross-section, rather than only as the dye outline seen on an angiogram.
An angiogram shows the shape of the channel, but not the thickness of the artery wall, how much calcium is there, or whether a stent has opened fully. Imaging from inside shows all three. This helps choose the right stent size, place it in healthy segments, and confirm it is fully expanded against the wall.
What the imaging trials show
Large trials in people with complex blockages have compared stenting guided by imaging with stenting guided by the angiogram alone. With imaging, fewer people later had problems with the treated artery, such as a heart attack in that artery, a repeat procedure on it, or death from a heart cause. In the largest of these trials, about 8 in 100 people had one of these problems over about 2 years with imaging, compared with about 12 in 100 without it (RENOVATE-COMPLEX-PCI, 2023). Not every trial showed a clear difference, but stents were better expanded with imaging.
People with a later problem in the treated artery over about 2 years, in 1,639 people with complex blockages. Source: Lee et al., NEJM 2023.
On this evidence, European guidelines (ESC 2024) strongly recommend imaging to guide stents in complex blockages, particularly the left main artery, branch points and long narrowings.
Measuring blood flow with a pressure wire
Some narrowings look moderate on an angiogram, and it is not always clear from the picture whether they limit blood flow. A pressure wire is a very thin wire passed beyond the narrowing. It measures the pressure on either side, which shows whether the narrowing is reducing blood flow to the heart muscle. The two common measurements are called FFR (fractional flow reserve) and iFR (instantaneous wave-free ratio).
If the narrowing does not limit flow, a stent is usually not needed and medicines are continued. European guidelines (ESC 2024) recommend this for moderate narrowings when blood flow has not already been tested. In the FAME trial, using the pressure wire to decide which narrowings to treat avoided unnecessary stents.
Treating without a permanent stent: drug-coated balloons
A drug-coated balloon is an angioplasty balloon coated with a medicine, usually paclitaxel or sirolimus. During an inflation of 30–60 seconds, the drug is pressed into the artery wall. The balloon opens the narrowing and leaves the drug behind to reduce re-narrowing, but no metal stays in the artery.
Avoiding a permanent implant can help in certain situations: inside a stent that has re-narrowed, in very small arteries where a stent would leave little room, and in people who cannot take long courses of blood-thinning tablets.
| Setting | What trials found | Current position |
|---|---|---|
| Re-narrowed stent (in-stent restenosis) | AGENT IDE: fewer repeat problems at the treated spot at 1 year (about 18 in 100 compared with about 29 in 100 with a plain balloon) | Established option |
| Small native arteries (<3 mm) | BASKET-SMALL 2: similar results to drug-eluting stents at 3 years | Reasonable option |
| Larger native arteries | REC-CAGEFREE I: a balloon-first approach did less well than a stent at 2 years | Stents remain preferred |
Hard, calcified arteries: lithotripsy and atherectomy
Over years, some plaque hardens with calcium that can be as stiff as bone and may form a complete ring inside the artery. Calcium stops a stent from opening fully, and a stent that is not fully expanded is more likely to cause problems later. Calcium tools prepare the artery before the stent goes in.
Intravascular lithotripsy (IVL)
A balloon sends out sonic pressure waves that crack calcium from within, similar in principle to the treatment used to break up kidney stones. In Disrupt CAD III (a single-arm, industry-funded study without a comparison group), about 92 in 100 people had no major heart problems in the first 30 days, and stents expanded well.
Rotational and orbital atherectomy
A tiny, fast-spinning, diamond-coated tip sands down hardened plaque. These are long-established, guideline-supported tools. The ECLIPSE trial (Lancet 2025) found routine orbital atherectomy did not improve one-year outcomes over careful balloon preparation in blockages suitable for either approach.
These techniques have made some heavily calcified arteries treatable with angioplasty when, in the past, bypass surgery may have been the only realistic option. The choice of tool depends on the pattern and depth of the calcium, which imaging from inside the artery can show.
Modern stents and shorter blood-thinning courses
Today's drug-eluting stents have struts (the metal mesh) roughly half the thickness of earlier designs, with improved coatings. Thinner struts heal over faster and are less likely to cause clots or re-narrowing.
Modern stents and newer trials mean many patients can take dual blood thinners for a shorter time. Dual antiplatelet therapy (DAPT) means aspirin plus a second tablet such as clopidogrel, ticagrelor or prasugrel. Shortening it lowers the risk of bleeding, and the second tablet may stop after only 1–3 months if your bleeding risk is high (ESC 2024). The usual durations are set out in medicines after a stent.
The right length of treatment is different for each person. Never stop blood-thinning tablets without speaking to your cardiologist first, even if a relative with a stent took them for a different length of time.
What has not changed
For stable coronary artery disease, medicines and risk-factor control are still the foundation of treatment. The ISCHEMIA trial (Maron et al., NEJM 2020) found that in stable patients, a routine procedure-first approach (stents or bypass) did not reduce death or heart attack overall compared with good medical therapy, although it relieved angina better in people with frequent symptoms. It didn't include people with significant left main disease, poor heart pumping function or a recent heart attack.
The advances in this article aim to make procedures more precise and results more durable. They do not change who needs one.
Control blood pressure
Well-controlled blood pressure reduces strain on the heart arteries and lowers risk.
Manage cholesterol and diabetes
Lowering cholesterol and controlling blood sugar slow plaque growth, with or without a stent.
Don't smoke
Stopping smoking is one of the most effective things you can do for your heart.
Stay active
Regular activity and taking your prescribed medicines matter alongside any procedure.
Questions to ask before a procedure
These questions can help you understand your treatment plan.
- Will a pressure wire be used to check whether a narrowing limits blood flow?
- Will you use imaging from inside the artery (IVUS or OCT) to guide the stent?
- Is my artery heavily calcified, and if so, how will it be prepared?
- Is a stent the right option for me, or could a drug-coated balloon suit my blockage?
- How long will I need two blood-thinning tablets, and why that length of time?
- What can I do with medicines and lifestyle to get a good long-term result?
For referring doctorsClinical notes for GPs
- Refer when: left main or true bifurcation disease, heavy calcification, in-stent restenosis or stent thrombosis, symptomatic CTO, or multivessel disease where PCI versus CABG is unclear.
- Evidence: ESC 2024 gives intracoronary imaging a Class I recommendation for left main and anatomically complex lesions, and FFR/iFR Class I for intermediate stenoses without prior ischaemia testing. RENOVATE-COMPLEX-PCI: target-vessel failure 7.7% vs 12.3% at a median 2.1 years. OCTOBER (bifurcations): MACE 10.1% vs 14.1% at 2 years. ILUMIEN IV: larger MSA and less stent thrombosis, no significant difference in target-vessel failure. AGENT IDE (ISR): target-lesion failure 17.9% vs 28.6% at 1 year.
- Availability: advanced calcium modification and routine intracoronary imaging are established in Australian practice but available only in selected centres, mostly larger public and private hospitals in capital cities.
- Medicines (DAPT defaults in letters): about 12 months after ACS, which the cardiologist may shorten or de-escalate to single antiplatelet therapy earlier (ACC/AHA 2025 ACS, Class 1; ESC 2023 ACS, IIa); about 6 months after elective PCI; 1–3 months if bleeding risk is high (ESC 2024 CCS). The letter should state the stop date.
- Don't stop the P2Y12 inhibitor early for dental work, minor skin surgery or colonoscopy without polypectomy. Defer elective non-cardiac surgery ideally 6 months after elective PCI and 12 months after ACS; if it can't wait, discuss with the cardiologist (aspirin usually continued).
- PPI: see the peri-procedure guidance. Avoid NSAIDs. Ticagrelor breathlessness is usually benign: review rather than stop.
- Long term: single antiplatelet (aspirin or clopidogrel) lifelong unless on an anticoagulant.
General information for referring practitioners. Check current MBS and PBS criteria before acting.
References
- Vrints C, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-3537. doi:10.1093/eurheartj/ehae177
- Lee JM, et al. Intravascular imaging-guided or angiography-guided complex PCI (RENOVATE-COMPLEX-PCI). N Engl J Med. 2023;388(18):1668-1679. doi:10.1056/NEJMoa2216607
- Holm NR, et al. OCT or angiography guidance for PCI in complex bifurcation lesions (OCTOBER). N Engl J Med. 2023;389(16):1477-1487. doi:10.1056/NEJMoa2307770
- Ali ZA, et al. Optical coherence tomography-guided versus angiography-guided PCI (ILUMIEN IV). N Engl J Med. 2023;389(16):1466-1476. doi:10.1056/NEJMoa2305861
- Tonino PAL, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention (FAME). N Engl J Med. 2009;360(3):213-224. doi:10.1056/NEJMoa0807611
- Yeh RW, et al. Paclitaxel-coated balloon vs uncoated balloon for coronary in-stent restenosis (AGENT IDE). JAMA. 2024;331(12):1015-1024. doi:10.1001/jama.2024.1361
- Jeger RV, et al. Long-term efficacy and safety of drug-coated balloons versus drug-eluting stents for small coronary artery disease (BASKET-SMALL 2): 3-year follow-up. Lancet. 2020;396(10261):1504-1510. doi:10.1016/S0140-6736(20)32173-5
- Gao C, et al. Drug-coated balloon angioplasty with rescue stenting versus intended stenting for the treatment of patients with de novo coronary artery lesions (REC-CAGEFREE I). Lancet. 2024;404(10457):1040-1050. doi:10.1016/S0140-6736(24)01594-0
- Hill JM, et al. Intravascular lithotripsy for treatment of severely calcified coronary artery disease (Disrupt CAD III). J Am Coll Cardiol. 2020;76(22):2635-2646. doi:10.1016/j.jacc.2020.09.603
- Kirtane AJ, et al. Orbital atherectomy versus balloon angioplasty before drug-eluting stent implantation in severely calcified lesions eligible for both treatment strategies (ECLIPSE). Lancet. 2025;405(10486):1240-1251. doi:10.1016/S0140-6736(25)00450-7
- Byrne RA, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826. doi:10.1093/eurheartj/ehad191
- Maron DJ, et al. Initial invasive or conservative strategy for stable coronary disease (ISCHEMIA). N Engl J Med. 2020;382(15):1395-1407. doi:10.1056/NEJMoa1915922