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


  • 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.