PCB vs SCB: has the balance begun to shift?

Paclitaxel-coated balloons (PCB) have long dominated the drug-coated balloon (DCB) landscape, supported by favourable pharmacokinetics and extensive randomised evidence. Sirolimus, by contrast, is inherently less lipophilic and biologically dependent on sustained arterial wall exposure, rendering simple balloon-coating strategies suboptimal. Consequently, early-generation sirolimus- coated balloons (SCB) were met with skepticism regarding effective drug transfer and durable tissue retention. Signals of attenuated late lumen gain with SCB in early randomised comparisons, including the TRANSFORM I, highlighted these limitations. However, subsequent randomised trials in both de novo lesions and in-stent restenosis have failed to demonstrate a meaningful difference in late lumen loss versus PCB.3 Crucially, in contemporary meta-analyses, even when modest angiographic differences are observed, these have not translated into significant differences in clinically relevant outcomes, including target lesion failure, repeat revascularisation, or myocardial infarction.