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Comparative effectiveness of percutaneous coronary intervention strategies for coronary small-vessel disease: a
Changjiang Deng1, Chao Fan1, Zhiyan Du1
1Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
Insights
Sirolimus-eluting stents (SES) offer the best outcomes for coronary small-vessel disease (SVD) percutaneous coronary intervention (PCI). Other stents and coated balloons are effective alternatives, while older methods are less beneficial.
Area of Science:
- Cardiology
- Interventional Cardiology
- Biomaterials Science
Background:
- Coronary small-vessel disease (SVD) presents unique challenges for percutaneous coronary intervention (PCI) due to increased risks of restenosis and ischemia.
- Current PCI strategies for SVD lack comparative performance data, hindering optimal device selection.
Purpose of the Study:
- To evaluate and rank different PCI strategies for treating coronary SVD.
- To provide comparative evidence for guiding device selection in SVD interventions.
Main Methods:
- A systematic review and network meta-analysis of English-language randomized controlled trials (RCTs) was performed.
- Studies were identified through comprehensive searches of major databases up to August 2025.
- Frequentist random-effects modeling was used to generate odds ratios and treatment rankings (SUCRA) for target lesion revascularization (TLR), binary restenosis (BR), and myocardial infarction (MI).
Main Results:
- The analysis included 39 trials with 14,503 patients.
- Sirolimus-eluting stents (SES) demonstrated the highest ranking for TLR (90.1%), binary restenosis (95.0%), and myocardial infarction (79.0%).
- Conventional methods like bare-metal stents (BMS), plain old balloon angioplasty (POBA), and gold-plated balloon angioplasty (GPBA) consistently ranked lowest across all evaluated outcomes.
Conclusions:
- Sirolimus-eluting stents (SES) provide the most consistent clinical benefit for patients with coronary SVD.
- Zotarolimus-eluting stents (ZES), everolimus-eluting stents (EES), and paclitaxel-coated balloons (DCB-PTX) represent effective alternatives in specific clinical scenarios.
- The study findings offer crucial comparative evidence to guide optimal device selection for PCI in SVD.
Background:
Coronary small-vessel disease (SVD) remains challenging for percutaneous coronary intervention (PCI) because small lumens magnify restenosis and ischemic risk. Multiple devices are available, yet their comparative performance is uncertain. This study evaluated and ranked PCI strategies for SVD.
Methods:
A systematic review and network meta-analysis was conducted in accordance with PRISMA. PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched from inception to 15 August 2025. Eligible studies were English-language randomized controlled trials enrolling adults with angiographic SVD defined as reference vessel diameter ≤3.0 mm, comparing PCI strategies, and reporting target lesion revascularization (TLR), binary restenosis (BR), or myocardial infarction (MI). A frequentist random-effects network meta-analysis generated odds ratios (ORs) with 95% confidence intervals (CIs) and treatment rankings using the surface under the cumulative ranking curve (SUCRA).
Results:
Thirty-nine trials including 14,503 patients met the criteria. For TLR (37 studies; 11,980 patients), the highest SUCRA values were observed with sirolimus-eluting stents (SES 90.1%), zotarolimus-eluting stents (ZES 83.9%), and everolimus-eluting stents (EES 82.2%). For BR (32; 6,468), SES, ZES, and paclitaxel-coated balloons (DCB-PTX) ranked highest (95.0%, 80.0%, and 78.3%). For MI (37; 11,602), SES, DCB-PTX, and ZES ranked highest (79.0%, 78.7%, and 68.5%). Representative effects showed SES reduced TLR versus bare-metal stents (BMS) (OR, 0.25; 95% CI, 0.15-0.43) and MI versus BMS (OR, 0.41; 95% CI, 0.21-0.79). Conventional approaches such as BMS, plain old balloon angioplasty (POBA), and gold-plated balloon angioplasty (GPBA) ranked lowest across outcomes.
Conclusion:
SES provides the most consistent clinical benefit for coronary SVD. ZES, EES, and DCB-PTX are effective alternatives in selected settings, whereas BMS, POBA, and GPBA are less effective. These findings offer comparative evidence to guide device selection in SVD.
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