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Sirolimus-Eluting Stents Rank Highest Across Outcomes in Coronary Small-Vessel PCI
Across 39 randomized trials enrolling more than 14,500 patients, sirolimus-eluting stents (SES) consistently ranked first for reducing target lesion revascularization, binary restenosis, and myocardial infarction in coronary small-vessel disease, cutting TLR risk by about 75% compared with bare-metal stents (OR 0.25, 95% CI 0.15–0.43). Zotarolimus-eluting stents, everolimus-eluting stents, and paclitaxel-coated balloons emerged as viable second-line alternatives, while bare-metal stents and balloon angioplasty strategies ranked last across all three outcomes.
What Was Studied
The study investigated which percutaneous coronary intervention (PCI) devices perform best in coronary small-vessel disease, defined as a reference vessel diameter of 3.0 mm or less. Small lumens amplify restenosis and ischemic risk after intervention, yet the comparative performance of the many available devices had not been rigorously ranked in a unified analysis.
How It Was Studied
Researchers conducted a pre-registered systematic review and frequentist random-effects network meta-analysis following PRISMA guidelines, searching five major databases from inception through August 15, 2025. Eligible studies were English-language randomized controlled trials enrolling adults with angiographically confirmed small-vessel disease who were treated with any PCI strategy and followed for at least one of three outcomes: target lesion revascularization (TLR), binary restenosis (BR), or myocardial infarction (MI). Thirty-nine trials met inclusion criteria, contributing between 6,468 and 11,980 patients per outcome depending on reporting availability. Treatment rankings were generated using the surface under the cumulative ranking curve (SUCRA), with higher SUCRA values indicating greater probability of being the best-performing strategy.
What Was Observed
- SES dominated TLR reduction: Sirolimus-eluting stents achieved the highest SUCRA rank for target lesion revascularization (90.1%), with a direct comparison showing approximately 75% lower odds of TLR versus bare-metal stents (OR 0.25, 95% CI 0.15–0.43). Zotarolimus-eluting stents (83.9%) and everolimus-eluting stents (82.2%) followed closely behind.
- SES, ZES, and DCB-PTX led on binary restenosis: For angiographic restenosis, SES ranked first (SUCRA 95.0%), followed by zotarolimus-eluting stents (80.0%) and paclitaxel-coated balloons (78.3%), suggesting that both drug-eluting stent and drug-coated balloon strategies can meaningfully suppress neointimal proliferation in small vessels.
- MI benefit was broadly shared among top-ranked devices: SES ranked highest for myocardial infarction reduction (SUCRA 79.0%), with paclitaxel-coated balloons nearly equivalent (78.7%) and ZES third (68.5%). Direct comparison showed SES reduced MI risk by roughly 60% relative to BMS (OR 0.41, 95% CI 0.21–0.79), a finding of particular importance given the ischemic consequences of restenosis in small territories.
- Conventional strategies ranked lowest uniformly: Bare-metal stents, plain old balloon angioplasty, and gold-plated balloon angioplasty placed at the bottom across all three outcome rankings, reinforcing the clinical obsolescence of these approaches relative to modern drug-eluting technologies.
Why This Matters
Coronary small-vessel disease represents a substantial proportion of PCI cases yet has historically been underrepresented in large pivotal trials, creating genuine uncertainty about optimal device selection. By pooling 39 randomized trials through network meta-analysis, this study provides a comparative hierarchy across multiple device classes simultaneously—something no individual trial could achieve. The consistent top ranking of SES and the strong performance of drug-coated balloons (which avoid permanent implants) are particularly informative for planning future device trials and informing guideline development.
How to Read This Result
SUCRA-based rankings reflect relative probability of superiority across the evidence network and should be interpreted cautiously, as differences in trial populations, lesion characteristics, follow-up duration, and outcome definitions across 39 heterogeneous studies may influence both effect estimates and rankings.
Limitations
The abstract does not explicitly report study limitations.