Which PCI strategy is best for small coronary artery stenosis?

Access to the full content of this site is available only to registered healthcare professionals. Register to read more


  • For treating stenoses in small coronary arteries, early-generation sirolimus-eluting stents (SES) offer the most favorable angiographic and clinical outcomes compared with the 5 most common types of percutaneous coronary intervention (PCI).

Study design

  • Meta-analysis of randomized trials comparing any PCI strategy for the treatment of coronary stenosis located exclusively in vessels of small diameter.
  • Trials with 2 or more arms were eligible.
  • 19 trials were included in final analysis, with 5072 patients comprising a network without closed loops among 5 identified interventions: early-generation SES, paclitaxel-eluting stents (PES), drug-coated balloons (DCB), bare-metal stents (BMS), and balloon angioplasty (BA).
  • Primary angiographic outcome was percentage diameter stenosis (%DS).

Key results

  • No dedicated trial evaluating new-generation drug-eluting stents was identified.
  • Early-generation SES yielded the best angiographic results according to %DS.
  • For %DS, SES was ranked as the most effective treatment, followed by PES and DCB.
  • In terms of absolute differences, SES yielded a reduction of 18% in diameter stenosis compared with DCB.
  • SES significantly reduced the risk for target-lesion revascularization compared with PES, DCB, BMS, and BA.


  • Some studies included in the analysis did not contain data on individual patients, so differences between PCI strategies could not be fully explored.
  • Most trials compared only BMS and BA strategies.
  • Several authors have received funding from companies that manufacturer devices used in these studies.

Why this matters

  • PCI in small coronary arteries is associated with an increased risk for lesion failure and restenosis, so choosing the most appropriate PCI strategy is key to good outcomes.