AbstractBackgroundDrug‐coated balloons (DCBs) have shown comparable results with drug‐eluting stents in small vessel disease (SVD) percutaneous coronary intervention (PCI) in terms of target vessel revascularization and a reduced incidence of myocardial infarction. However, the relatively high rate of bail‐out stenting (BOS) still represents a major drawback of DCB PCI.AimsThe aim of the study was to investigate the clinical, anatomic, and procedural features predictive of BOS after DCB PCI in SVD.MethodsWe included all consecutive patients undergoing PCI at our institution between January 2020 and May 2022 who were treated with DCB PCI of a de novo lesion in a coronary vessel with a reference vessel diameter (RVD) between 2.0 and 2.5 mm. Angiographic success was defined as a residual stenosis <30% without flow‐limiting dissection. Patients who did not meet these criteria underwent BOS.ResultsA total of 168 consecutive patients and 216 coronary stenoses were included. The rate of bail‐out stent was 13.9%. On multivariate analysis, DCB/RVD ratio (odds ratio [OR]: 4.39, 95% confidence interval [CI]: 1.71–11.29, p < 0.01), vessel tortuosity (OR: 7.00, 95% CI: 1.66–29.62, p < 0.01), distal vessel disease (OR: 5.66, 95% CI: 2.02–15.83, p < 0.01), and high complexity (Grade C of ACC/AHA classification) coronary stenoses (OR: 6.31, 95% CI: 1.53–26.04, p = 0.01) were independent predictors of BOS.ConclusionsBOS is not an infrequent occurrence in DCB PCI of small vessels and is correlated with vessel tortuosity, distal diffuse vessel disease, higher lesion complexity, and balloon diameter oversizing.