Stent-less percutaneous coronary intervention using directional coronary atherectomy and drug-coated balloon angioplasty for a stenotic lesion in a patient with vasospastic angina.

We report a case of vasospastic angina with clinically significant coronary stenosis, which was successfully treated with stent-less percutaneous coronary intervention (PCI). A man in his 40s with recurrent rest angina was transported to the Emergency Department. Upon arrival, his electrocardiogram showed transient ST-segment elevation. Coronary angiography showed considerable proximal left anterior descending artery stenosis without impaired flow, suggesting vasospastic involvement. Instead of proceeding directly with PCI, a vasospasm provocation test was conducted, and it confirmed severe vasospasm at the stenotic site. Initial treatment with a calcium channel blocker was initiated because of the substantial contribution of vasospasm to the patient's symptoms. However, as exertional angina became predominant, revascularization was considered necessary. Considering the potential for drug-eluting stents to exacerbate coronary vasospasm in the peri-stent region, we opted for a stent-less PCI using directional coronary atherectomy followed by drug-coated balloon angioplasty, achieving a favorable outcome. This case suggests the importance of recognizing vasospasm even in patients with considerable stenosis and highlights the role of vascular functional assessment in guiding PCI decisions. Stent-less PCI using directional coronary atherectomy and drug-coated balloon may be an effective strategy in such cases, reducing the risk of refractory vasospasm associated with drug-eluting stent implantation. Learning objective: Vasospastic angina with considerable coronary artery stenosis is not rare. Drug-eluting stents may cause persistent refractory vasospasm in such cases. Careful evaluation of the patient's clinical history and appropriate vascular function tests can help avoid this complication. Stent-less percutaneous intervention using directional coronary atherectomy and drug-coated balloon angioplasty represents a viable alternative in selected cases.