Percutaneous Coronary Interventions for the Treatment of Stenoses in Small Coronary Arteries: A Network Meta-Analysis

doi:10.1016/j.jcin.2016.03.025

JACC: Cardiovascular Interventions

Volume 9, Issue 13, 11 July 2016, Pages 1324-1334

https://doi.org/10.1016/j.jcin.2016.03.025 Get rights and content

Under an Elsevier user license

open archive

Abstract

Objectives

This study evaluated the most appropriate percutaneous coronary intervention (PCI) for the treatment of stenoses in small coronary arteries.

Background

PCI in small coronary arteries is associated with an increased risk of lesion failure and restenosis.

Methods

Randomized trials comparing different PCI strategies were identified through a broad search of published reports. Primary angiographic outcome was %DS (%DS). A pairwise meta-analysis was performed by using random effects model, followed by a network meta-analysis synthesizing direct and indirect evidence.

Results

Overall, 19 trials were eligible, which included 5,072 patients comprising a network without closed loops among 5 identified interventions (early generation sirolimus-eluting stents [SES], paclitaxel-eluting stents [PES], drug-coated balloons [DCB], bare-metal stents [BMS], and balloon angioplasty [BA]). No dedicated trial was identified evaluating new generation drug-eluting stents. Early generation SES yielded the best angiographic results according to %DS. For %DS, SES was ranked as the most effective treatment, followed by PES (standardized mean differences [SMD]: –0.44; 95% confidence interval [CI]: –0.92 to 0.05 vs. SES) and DCB (SMD: –0.89; 95% CI: –1.53 to –0.25 vs. SES). In terms of absolute differences, SES yielded a reduction of 18% in diameter stenosis compared to DCB. SES significantly reduced the risk of target-lesion revascularization compared to PES (odds ratio [OR]: 0.39; 95% CI: 0.16 to 0.93), DCB (OR: 0.34; 95% CI: 0.10 to 0.97), BMS (OR: 0.21; 95% CI: 0.13 to 0.36), and BA (OR: 0.16; 95% CI: 0.09 to 0.29).

Conclusions

Early generation SES yielded the most favorable angiographic and clinical outcomes for the treatment of stenoses in small coronary arteries. New generation DES need to be evaluated against this standard in future randomized trials.

Key Words

coronary disease

drug-coating balloon(s)

drug-eluting stent(s)

network meta-analysis

small coronary arteries

Abbreviations and Acronyms

%DS

percent diameter stenosis

balloon angioplasty

BMS

bare-metal stent(s)

CAD

coronary artery disease

DCB

drug-coated balloon(s)

DES

drug-eluting stent(s)

PCI

percutaneous coronary interventions

PES

paclitaxel-eluting stent(s)

SES

sirolimus-eluting stent(s)

TLR

target-lesion revascularization

Cited by (0)

: Dr. Jüni is currently affiliated with the Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada. Dr. Piccolo has received research support from Italian Society of Cardiology and Veronesi Foundation–Cardiovascular Research. Dr. Valgimigli has received honoraria and research grants from Merck, Iroko, Eli Lilly, Medtronic, The Medicines Company, Daiichi Sankyo, St. Jude Medical, Abbott Vascular, Cordis, Carbostent, Implantable Devices, and Terumo. Dr. Räber is an advisory board member of Abbott Vascular; and has received speaker fees from St. Jude Medical. Dr. Jüni has received research institutional grants from AstraZeneca, Biotronik, Biosensors International, Eli Lilly, and The Medicines Company; and is an unpaid committee member of trials funded by Abbott Vascular, Biosensors, Medtronic, AstraZeneca, Biotronik, St. Jude Medical, and The Medicines Company. Dr. Windecker has received institutional research grants from Biotronik, Abbott Vascular, Boston Scientific, Biosensors, Medtronic, Edwards Lifesciences, Inc., and St. Jude Medical; and speakers fees from AstraZeneca, Eli Lilly, Abbott Vascular, Biosensors, Biotronik, Boston Scientific, Medtronic, Eli Lilly, and AstraZeneca. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.