Hybrid Approach to Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion and Diffuse Coronary Artery Disease

The coexistence of a chronic total occlusion (CTO) of the mid right coronary artery (RCA) with diffuse distal disease poses a significant challenge for percutaneous coronary intervention. Long drug-eluting stents (DES) in small, diffusely diseased vessels increase restenosis and stent thrombosis risk and add excessive metal burden. An individualized hybrid strategy combining different revascularization modalities can minimize implanted metal while achieving effective myocardial perfusion. Aim. To demonstrate the possibilities and clinical feasibility of using a hybrid approach combining drug-eluting stent implantation and drug-coated balloon (DES+DCB) angioplasty. Description. We report a 49-year-old man with stable ischemic heart disease, postinfarction cardiosclerosis, and angina. Coronary angiography identified a mid-RCA CTO and diffuse 70-90 % disease of the posterior descending artery (PDA) and posterolateral branch (PLB), without discrete focal lesions. After successful CTO recanalization, a DES was implanted in the occluded mid-RCA to restore antegrade flow. Given the small caliber and diffuse involvement of the PDA, vessel preparation was followed by drug-coated balloon (DCB) angioplasty to avoid permanent metal implantation. The PLB demonstrated significant residual stenosis and impaired flow after initial treatment, requiring DES implantation to achieve an optimal angiographic result. The combined approach restored full patency of the RCA and its distal branches without peri-procedural complications. Post-procedure, the patient experienced angina relief and modest improvement in left ventricular ejection fraction. Conclusions. A hybrid DES+DCB strategy enabled mechanical scaffold where necessary (CTO segment) while minimizing metal load in diffusely diseased, small-caliber distal vessels. In patients with diffuse distal coronary disease, DCBs represent a reasonable alternative to long stents and may reduce restenosis and late thrombotic events. Successful application of this strategy depends on meticulous lesion and vessel preparation. The presented case illustrates the value of individualized revascularization tailored to lesion morphology and segmental significance. While promising for CTOs with diffuse distal disease, DES+DCB hybrid strategies warrant further evaluation in prospective studies to define optimal patient selection and long-term outcomes.