DES, DCB and BRS
In 2026, the most rational narrative in the field of coronary intervention will no longer be “who replaces whom,” but rather “who is optimal in which scenario.”
Although drug-eluting stents (DES) still hold over 85% of the market share due to their exceptional cost-effectiveness after centralized procurement and their irreplaceable ability to handle emergency/complex lesions, making them the absolute “all-rounder,” in the 15% gap that DES cannot perfectly cover, DCB (drug-eluting balloon) and BRS (resorbable stent) have completed a profound “scenario positioning.”
The relationship between the two has evolved from early “fighting side by side” to today’s “misaligned complementarity and marginal friction.”
I. DES: An Unshakeable "Silent Foundation"
Before discussing “non-implantable” solutions, we must recognize the current status of DES.
Full-scenario coverage: Whether it’s emergency intervention for acute myocardial infarction or complex lesions with severe calcification and tortuous vessels, the immediate radial support provided by DES remains the only solution.
Economic principle: Under DRG/DIP payment reform, the extremely low cost of DES makes it a “ballast” for hospital operations.
Positioning: DES is the default option. The real opportunity for DCB and BRS only arises when DES is “unsuitable” or “uneconomical.”
II. DCB: A Pragmatic "Sports Monopolist"
The success of DCB lies in its precise targeting of the “pain points” of DES—small vessels and restenosis.
1. From “Alternative” to “Standard Answer”
Following the JACC declaration in 2025, DCB’s position in the field of <2.75mm small vessels and in-stent restenosis (ISR) is unshakeable, accounting for over 80% of clinical applications.
Technological Closed Loop: Products such as Cosell’s spinous process balloon and Biodori’s DCB have built a mature “adequate pretreatment + precise drug delivery” system, greatly reducing the risk of aortic dissection.
Clinical Logic: “Short-term high efficiency + no foreign body residue.” If the procedure fails, it can be switched to “rescue stent implantation” at any time. This flexibility, allowing for both offensive and defensive approaches, gives doctors the confidence to use it on a large scale.
2. The Other Side of the Coin:
DCB Limitations
DCB is not a panacea; its success highly depends on the quality of “vascular preparation”:
Severe calcification: If rotational ablation or cutting is insufficient, the drug cannot penetrate and is prone to elastic recoil. In this case, DCB’s effectiveness is far inferior to DES.
Long lesions: Repeated long balloon dilation may accumulate vascular damage, increasing the risk of perforation.
Conclusion: DCB is effective for simple/moderate lesions, but DES is still necessary as a backup for complex calcifications and long lesions.
III. BRS: Rational Adherence to High-Value Narrow Passages
Unlike the rapid advancements of DCB, BRS faced greater challenges in 2026, but also a more sober approach.
1. A Breakthrough After Iteration: New-generation products like NeoVas and Minimally Invasive have significantly improved upon the weak support and high thrombosis rates of earlier products by optimizing bridge thickness and degradation rate. However, technological advancements haven’t changed its inherently high barrier to entry.
2. Stringent Indications and Technological Barriers: The clinical application of BRS exhibits extremely high selectivity and dependence, forming a natural barrier to its market expansion: Extremely stringent lesion selection: Due to material limitations, BRS is currently mainly suitable for large vessels (>3.0mm), non-calcified, and young patients (<45 years old). For calcified, small, tortuous, and ostial lesions, its safety and efficacy remain challenging, and are generally considered contraindicated or not the preferred option clinically.
High dependence on imaging guidance: BRS implantation requires extremely high wall apposition; IVUS/OCT guidance throughout the procedure has become standard operating procedure. Even minor apposition defects can significantly increase the risk of late thrombosis, making its operational tolerance far lower than that of DES.
Essential characteristic: BRS is not a universal device, but rather a “highly specialized, sophisticated device.” It sacrifices universality in exchange for the potential restoration of vascular physiological function in a specific population.
3. The reality of “high praise but low adoption”
This rigorously selected population represents less than 3% of the total population. High costs and a steep learning curve mean that BRS is destined to remain a “high-value, low-scale” specialty technology, unlikely to become a mainstream cash cow.
IV. Endgame: Misalignment and Complementarity, and Friction at the Edge
The market in 2026 has formed a clear pyramid ecosystem:
Base (DES): Handling 85% of routine and complex cases, providing comprehensive support.
Body (DCB): Monopolizing the small vessel and ISR market, pragmatic and efficient.
Peak (BRS): Steadfastly addressing the physiological reconstruction needs of young, large vessels, upholding ideals.
Where is the competition? The real friction occurs only in the ambiguous zone of “medium to large vessels, non-calcified, and relatively young.”
With the enhancement of DCB pretreatment capabilities (such as larger balloons), DCB is gradually encroaching on the periphery of what was originally BRS’s territory.
This has forced BRS to further shrink into the “ultra-high-end, ultra-young” niche market, relying on its unique selling point of “complete restoration of vascular physiological function” to maintain its presence.
In 2026, the “non-implantable” era will see the fervor subside and return to rationality.
DES, with its “all-around support,” bears the weight of life; DCB, with its “pragmatic and efficient” approach, wins in its specific niche;
BRS, with its ideal of “physiological reconstruction,” safeguards the future under strict constraints.
These three are not in a life-or-death struggle, but rather coexist in a staggered yet symbiotic relationship, jointly forming a new ecosystem of more precise and safer coronary artery treatment.