Early-Generation Sirolimus-Eluting Stents Most Effective for Stenosis in Small Coronary Arteries

A meta-analysis compared methods of percutaneous coronary intervention for the treatment of stenosis in small coronary arteries.

Early-generation sirolimus-eluting stents (SES) produced the most favorable angiographic and clinical outcomes in percutaneous coronary intervention (PCI) to treat stenoses in small coronary arteries, according to data published in the JACC: Cardiovascular Interventions.

In prior studies, PCI in small coronary arteries has been associated with an increased risk of lesion failure and restenosis. Researchers conducted a meta-analysis to evaluate available interventions, estimate the relative effectiveness between pairs of interventions, and determine the most appropriate PCI strategy to treat stenosis in small coronary arteries.

The meta-analysis was comprised of 19 randomized trials that compared different PCI strategies. The analysis included 5072 patients comprising a network without closed loops between the 5 identified interventions, including early-generation SES, paclitaxel-eluting stents (PES), drug-coated balloons, bare-metal stents (BMS), and balloon angioplasty. The trials included in the analysis did not include new-generation drug-eluting stents.

They performed a pairwise analysis using a random-effects model, which was followed by a network meta-analysis that analyzed direct and indirect evidence. The primary outcome was percent diameter stenosis.

Early-generation SES had the best angiographic results. In terms of diameter stenosis, SES was ranked the most effective treatment, followed by PES (standard mean difference vs SES: –0.44; confidence interval [CI]: –0.92 to 0.05), and DCB (standard mean difference vs SES: –0.89; CI: –1.53 to –0.25).

Researchers also measured absolute differences and found that SES had a significant diameter stenosis reduction of 18% compared with drug-coated balloons. SES also reduced the risk of target-lesion revascularization compared with PES (odds ratio [OR]: 0.39; CI: 0.16-0.93), drug-coated balloons (OR: 0.34; CI: 0.10-0.97), BMS (OR: 0.21; CI: 0.13-0.36), and balloon angioplasty (OR: 0.16; CI: 0.09-0.29).

“Another finding of this network meta-analysis is that the use of BA [balloon angioplasty] for the treatment of small vessels should be avoided since this treatment modality resulted in the lowest ranking for all study outcomes,” the authors noted.

“It is noteworthy that direct evidence from randomized trials was limited exclusively to the comparison of BMS vs BA, and therefore the comparative evaluation of BA with newer techniques was possible only indirect through the network meta-analysis.”

Researchers added that future studies should focus on evaluating the role of different platforms of new-DES.

“The availability of new-generation DES with 2.25 and 2.00 mm diameter may further improve the feasibility and performance of coronary stenting in vessels,” they wrote. “Finally, new-generation DES have been associated with an improved safety and efficacy profile compared to early-generation DES and DCB in different settings.”


Siontis GCM, Piccolo R, Praz F, et al. Percutaneous coronary intervention of the treatment of stenoses in small coronary arteries: a network meta-analysis. JACC Cardiovasc Interv. 2016. doi: 10.1016/j.jcin.2016.03.025.