PCI for small-vessel coronary disease: How should cardiologists proceed?

Newer-generation drug-eluting stents (n-DES) are a more effective option for the percutaneous treatment of small-vessel coronary disease (SVCD) than drug-coated balloons (DCBs), according to new findings published in JACC: Cardiovascular Interventions. DCBs, the study’s authors noted, were associated with a much higher risk of restenosis.

The researchers assessed data from more than 14,000 patients who underwent percutaneous coronary intervention (PCI) for SVCD in Sweden from April 2009 to July 2017. The data, part of the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), included more than 13,000 patients treated with n-DES and more than 1,500 treated with DCBs.

Overall, there was a “significantly higher” risk of restenosis after a three-year follow-up for patients who underwent PCI with DCBs. The risk of all-cause death and MI were “comparable” between the two groups. Also, treatment with n-DES was used more often when the patient presented with an especially complex or heavily calcified lesion.

“Although confirmation by large randomized studies are warranted, our research suggests that DCBs are not an equally effective alternative to n-DES for the treatment of small-vessel CAD,” wrote lead author Angelo Silverio, MD, Uppsala University in Sweden, and colleagues. “DCB use should be therefore limited to selected cases for which stent implantation is not desirable.”

In a related editorial, also published in JACC: Cardiovascular Interventions, three researchers complimented the work of Silverio et al.

“Unlike prior studies, newer generations of both DES and DCBs were evaluated, and patients who underwent bailout stenting following DCB treatment were excluded from analysis,” wrote lead author Francesco Giannini, MD, Maria Cecilia Hospital in Italy, and colleagues. “Importantly, a broad range of devices with varying construction and pharmacological characteristics were included.”

The editorial’s authors did point out that Silverio’s team reached a different conclusion than several other recent studies. The BELLO study by Latib et al., for example, found “no differences in terms of rates of restenosis, revascularizations and major adverse cardiovascular events.”

“This apparent divergence in reported outcomes requires a close examination if we are to clear the fog surrounding the treatment of SVCD,” Giannini and colleagues wrote. “This disparity can be partially explained by the heterogeneity in the reported research. Differences in definitions of small vessels, devices implanted, implantation technique, use of pharmacological therapies, and outcomes evaluated (angiographic or clinical) vary significantly across the different trials and studies.”