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Early generation sirolimus-eluting stents (SES) lead the pack for percutaneous coronary intervention (PCI) in small coronary arteries, according to a network meta-analysis.

SES was the most effective device for reducing diameter stenosis, , of Bern University Hospital in Switzerland, and colleagues reported online in . The absolute difference in percentage diameter stenosis compared with SES was:

• 9% against paclitaxel-eluting stents (PES, 95% CI 1-18%)
• 18% against drug-coated balloons (DCB, 95% CI 5-32%)
• 29% against bare-metal stents (BMS, 95% CI 22-35%)
• 32% against balloon angioplasty (95% CI 25-39%)

Target lesion revascularization rates also favored SES when compared with:

• PES (odds ratio [OR] 0.39, 95% CI 0.16-0.93)
• DCB (OR 0.34, 95% CI 0.10-0.97)
• BMS (OR 0.21, 95% CI 0.13-0.36)
• Balloon angioplasty (OR 0.16, 95% CI 0.09-0.29).

"Early-generation SES yielded the most favorable angiographic and clinical outcomes for the treatment of stenoses in small coronary arteries," the investigators concluded. "New-generation drug-eluting stents [DES] need to be evaluated against this standard in future randomized trials."

In any case, they cautioned, "BMS and balloon angioplasty had the worst ranking position for all study outcomes and therefore cannot be considered as effective alternatives for patients undergoing PCI of small vessel disease."

The concept of revascularization delivering an antiproliferative drug via nonstent-based platforms had been attractive, but "the results of the present study indicate that DES -- particularly SES -- are superior to DCB for the treatment of small vessel coronary artery disease by providing superior angiographic and clinical outcomes," Windecker's group concluded.

SES recipients experienced far fewer myocardial infarctions compared with their peers getting balloon angioplasty (OR 0.38, 95% CI 0.18-0.89), though other stents performed just as well in this regard.

Windecker's analysis included 19 trials and 5,072 patients who received PCI for CAD in small coronary arteries.

Newer-generation DES recipients were not included in the meta-analysis.

That lack "cannot be considered a limitation of the present study but rather of the currently available evidence," according to , and , both of Hospital Universitario de La Princesa in Madrid.

In an , however, the pair noted that the definition of "small vessel" varied across the trials studied, with some vessels larger than 2.5 mm inappropriately included.