Reconsider the future of interventional cardiology: restoration, reappraisal, and revolution

As we stand at the threshold of a new year, interventional cardiology finds itself not merely advancing, but transforming. For decades, our discipline has been defined by mechanical mastery[1–2]: dilating stenoses, implanting stents, restoring flow. Yet the horizon before us suggests something more ambitious. We are moving beyond the era of metallic permanence into an age defined by biological restoration, physiological precision, and systemic risk modulation[3–5]. This is not a rejection of the achievements that shaped modern percutaneous coronary intervention (PCI); rather, it is a reappraisal of its foundations and a revolution in its purpose. The central question is no longer simply how to reopen an artery, but how to heal a vessel, prevent recurrence, and personalize therapy across the continuum of cardiovascular risk. The future interventionalist must therefore evolve from procedural technician to vascular biologist, imaging strategist, and systems-level thinker. Three major currents define this transition: the pursuit of implant-free therapies, the ascendancy of multimodal imaging and artificial intelligence (AI), and the renaissance of precision pharmacotherapy. INTERVENTIONAL CARDIOLOGY WITHOUT IMPLANTS: THE “LEAVE NOTHING BEHIND” PHILOSOPHY For decades, permanent metallic scaffolds have been the cornerstone of PCI. Yet the very presence of a metallic cage can compromise vasomotion, sustain chronic inflammation, predispose to late and very late stent thrombosis, and constrain future revascularization options. These long-term biological trade-offs have catalyzed a paradigm shift. The “leave nothing behind” philosophy now seeks transient scaffolding or direct vessel-wall modulation, restoring patency without permanent implants. The resurgence and refinement of drug-coated balloons Drug-coated balloons (DCBs) have moved beyond their traditional role in in-stent restenosis and are now being evaluated for selective de novo coronary disease. The Paclitaxel-coated Balloon for Treatment of De-novo Non-complex Coronary Artery Lesions (REC-CAGEFREE I) Trial demonstrated that paclitaxel-coated balloon angioplasty with provisional rescue stenting did not achieve non-inferiority compared with upfront drug-eluting stents (DES) at 1 and 2 years, and showed higher device-oriented adverse outcomes at 3 years[6–7]. Importantly, this difference was largely driven by target lesion revascularization, raising the possibility that “delayed rescue stenting” strategies may require refinement. Notably, no significant differences were observed in all-cause death, cardiac death, target vessel myocardial infarction, or major bleeding. Parallel to paclitaxel platforms, sirolimus drug-eluting balloons (SEBs) have emerged as promising alternatives. Early studies[8] and the Clinical Study of MDK-1901 for Patients with Superficial Femoral and Popliteal Artery Lesions (SELUTION SFA JAPAN) Trial[9] demonstrated feasibility, safety, and efficacy in peripheral artery disease. The ongoing The SELUTION DeNovo Study will be pivotal in determining whether SEBs can match or surpass DES performance in coronary lesions[10]. The intrinsic advantage of DCBs lies in delivering antiproliferative therapy directly to the vessel wall without leaving behind a scaffold, preserving vasomotion and eliminating long-term implant-related risks. Future progress will depend on optimized drug-transfer kinetics, dedicated solutions for calcified lesions (potentially in conjunction with atherectomy), and advanced imaging-guided patient selection. Next-generation bioresorbable scaffolds The withdrawal of the first-generation Absorb bioresorbable scaffold (BRS) from the U.S. market marked a sobering pause in the BRS journey. However, the extended follow-up of Absorb IV Randomized Controlled (ABSORB IV) Trial demonstrated only a modest 3% absolute increase in target vessel failure at 5 years, with comparable restenosis rates[11], suggesting that technique and design evolution may mitigate earlier concerns. Similarly, 5-year outcomes of the XINSORB bioresorbable sirolimus-eluting scaffold in first-in-human de novo lesions provided important long-term safety data[12]. Learning from early limitations, next-generation BRS platforms now feature: thinner struts, improved radial strength, and faster and more predictable resorption profiles. Material science has advanced beyond early poly-L-lactic acid (PLLA) designs to include magnesium-based scaffolds (e.g., Magmaris) and novel polymer blends such as polycaprolactone (PCL) and tyrosine-derived polycarbonates. Magnesium-based scaffolds demonstrate a biphasic safety profile, tolerable early risk followed by sustained long-term safety[13]. Moreover, three-dimensional (3D) printing technology has also been pursued and incorporated into BRS fields, with studies showing a precision patient solution with clinical safety[14]. These results shed light on the renewed future of next-generation BRS. THE EYE OF THE CLINICIAN: THE PIVOTAL ROLE OF MULTIMODAL IMAGING From luminal silhouettes to integrated anatomy and physiology Angiography provides a two-dimensional lumenogram; intravascular imaging reveals the vessel’s true architecture. Contemporary practice increasingly relies on intravascular ultrasound (IVUS), optical coherence tomography (OCT), near-infrared spectroscopy (NIRS), and emerging hybrid systems. Dual-probe and multimodality catheters now undergoing in vivo validation promise real-time histopathological characterization, precise PCI planning, and meticulous post-implant optimization[15–19]. Such technologies reduce procedural complications and improve long-term outcomes. Physiological assessment has likewise matured. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) remain gold standards, but angiography-derived, imaging-derived, and coronary computed tomography (CT)–derived computational assessments are rapidly gaining validation. The integration of anatomy and physiology redefines lesion assessment from static stenosis grading to dynamic ischemia prediction. Fusion imaging and AI: the pre-procedural blueprint The convergence of multimodal imaging with AI represents one of the most transformative shifts in contemporary cardiology. AI-driven plaque characterization allows automated identification of high-risk morphological features associated with rupture, while potentially uncovering novel patterns beyond human perception. Fusion imaging platforms integrate angiography, intracoronary imaging, and CT datasets into comprehensive patient-specific 3D coronary reconstructions. The emerging concept of the “digital twin” of the coronary tree may soon enable simulation of stent sizing, expansion, flow dynamics, and pharmacologic responses before a wire ever crosses the lesion. Crucially, AI performs complex measurements within seconds, reducing operator variability, eliminating manual errors, and liberating clinicians to focus on decision-making rather than measurement. THE RENAISSANCE OF PHARMACOTHERAPY: TARGETING RESIDUAL RISK While devices repair focal obstructions, systemic therapies reshape the vascular milieu. The residual risk observed after technically successful PCI demands increasingly precise pharmacologic strategies. Lipid management: from antibodies to gene silencing The era of lipid lowering has expanded far beyond statins. Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies reshaped low-density lipoprotein cholesterol (LDL-C) management, and the ORION program[20] established inclisiran, a small interfering ribonucleic acid (RNA) therapy, as a durable, biannual approach to LDL reduction. The Evaluation of Major Cardiovascular Events in Participants With, or at High Risk for, Cardiovascular Disease Who Are Statin Intolerant Treated With Bempedoic Acid (ETC-1002) or Placebo (CLEAR Outcomes) Trial[21] confirmed that bempedoic acid reduces major adverse cardiovascular events in statin-intolerant patients, reinforcing that LDL lowering, regardless of elevated lipoprotein(a)(Lp[a]), affecting approximately 20% of the population, remains one of the most critical unmet needs. RNA-based therapies targeting LPA mRNA, currently evaluated in Assessing the Impact of Lipoprotein (a) Lowering With Pelacarsen (TQJ230) on Major Cardiovascular Events in Patients With CVD (Lp[a]HORIZON) (HORIZON)[22] and Olpasiran Trials of Cardiovascular Events And LipoproteiN(a) Reduction-DOSE Finding Study (OCEAN[a]-DOSE)[23] Trials, signal a new era of genetically guided intervention. As polygenic risks scoring and genomic profiling enter routine cardiology practice, preventive therapy will become increasingly individualized. The inflammatory hypothesis realized The inflammatory hypothesis of atherosclerosis has matured from biomarker association to mechanistic clarity. Clonal hematopoiesis of indeterminate potential (CHIP) has emerged as a powerful age-related driver of cardiovascular risk. Somatic mutations in hematopoietic stem cells confer clonal expansion and heightened inflammatory signaling, independently predicting coronary artery disease[24], arrhythmias[25], and heart failure[26]. CHIP may explain persistent residual risk despite optimal lipid and blood pressure control. Simultaneously, advances in single-cell transcriptomics reveal that neutrophils are not terminal “suicidal killers,” but plastic, heterogeneous populations. Distinct subsets participate in angiogenesis and tissue repair[27]. Future therapies may aim not at indiscriminate suppression, but at transcriptional reprogramming, redirecting inflammatory cells toward regenerative phenotypes. Antithrombotic precision: hemostasis without hemorrhage The ultimate goal of antithrombotic therapy is the prevention of ischemia without provoking bleeding. As stent platforms improve and patient populations age, the paradigm is shifting from prolonged potency to strategic minimalism. Dual antiplatelet therapy (DAPT) de-escalation and monotherapy strategies are redefining post-PCI care. Short DAPT (1–3 months) followed by P2Y12 inhibitor monotherapy has demonstrated safety in selected patients. The Percutaneous Coronary Intervention Followed by Antiplatelet Monotherapy in the Setting of Acute Coronary Syndromes (NEOMINDSET) Trial advanced this concept further, exploring complete cessation of antiplatelet therapy after confirmation of optimal stent healing by OCT[28]. These data suggest a future where therapy duration is dictated by biological healing rather than calendar convention. Parallel innovation targets the coagulation cascade itself. Factor XI/XIa inhibitors such as asundexian and milvexian aim to decouple antithrombotic efficacy from hemostatic integrity by selectively modulating the intrinsic pathway[29]. If successful, these agents may provide protection from pathological thrombosis while preserving physiological hemostasis. CONCLUSIONS: FROM MECHANIC TO VASCULAR BIOLOGIST The interventional cardiologist of tomorrow will not be defined solely by technical dexterity. The future belongs to clinicians who integrate bioresorbable or implant-free devices, high-resolution imaging, AI, and precision pharmacotherapy into a coherent, patient-centered strategy. We are entering an era where we do not merely scaffold arteries; furthermore, we restore vascular biology. Let this year mark our commitment to precision: the right patient, the right device, the right drug, at the right time, guided not only by anatomy, but by physiology and biology. The revolution has already begun. AUTHOR CONTRIBUTIONS JBG solely conceived, drafted, and revised the manuscript. He approved the final version and assumes full responsibility for its accuracy and integrity. CONFLICT OF INTEREST STATEMENT Junbo Ge is the Editor-in-Chief of Cardiology Plus. The article was subject to the journal’s standard procedures, with peer review handled independently of the Editorial Board members and their research groups. DATA SHARING STATEMENT Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.