• Meta-Analysis: Sirolimus-Eluting Stents Best for Small Vessel PCI But newer-generation stents not included in comparisons

    Early generation sirolimus-eluting stents (SES) lead the pack for percutaneous coronary intervention (PCI) in small coronary arteries, according to a network meta-analysis.

    SES was the most effective device for reducing diameter stenosis, Stephan Windecker, MD, of Bern University Hospital in Switzerland, and colleagues reported online in JACC: Cardiovascular Interventions. The absolute difference in percentage diameter stenosis compared with SES was:

    • 9% against paclitaxel-eluting stents (PES, 95% CI 1-18%)
    • 18% against drug-coated balloons (DCB, 95% CI 5-32%)
    • 29% against bare-metal stents (BMS, 95% CI 22-35%)
    • 32% against balloon angioplasty (95% CI 25-39%)

    Target lesion revascularization rates also favored SES when compared with:

    • PES (odds ratio [OR] 0.39, 95% CI 0.16-0.93)
    • DCB (OR 0.34, 95% CI 0.10-0.97)
    • BMS (OR 0.21, 95% CI 0.13-0.36)
    • Balloon angioplasty (OR 0.16, 95% CI 0.09-0.29).

    “Early-generation SES yielded the most favorable angiographic and clinical outcomes for the treatment of stenoses in small coronary arteries,” the investigators concluded. “New-generation drug-eluting stents [DES] need to be evaluated against this standard in future randomized trials.”

    In any case, they cautioned, “BMS and balloon angioplasty had the worst ranking position for all study outcomes and therefore cannot be considered as effective alternatives for patients undergoing PCI of small vessel disease.”

    The concept of revascularization delivering an antiproliferative drug via nonstent-based platforms had been attractive, but “the results of the present study indicate that DES — particularly SES — are superior to DCB for the treatment of small vessel coronary artery disease by providing superior angiographic and clinical outcomes,” Windecker’s group concluded.

    SES recipients experienced far fewer myocardial infarctions compared with their peers getting balloon angioplasty (OR 0.38, 95% CI 0.18-0.89), though other stents performed just as well in this regard.

    Windecker’s analysis included 19 trials and 5,072 patients who received PCI for CAD in small coronary arteries.

    Newer-generation DES recipients were not included in the meta-analysis.

    That lack “cannot be considered a limitation of the present study but rather of the currently available evidence,” according to Fernando Alfonso, MD, PhD, and Marcos García-Guimaraes, MD, both of Hospital Universitario de La Princesa in Madrid.

    In an accompanying editorial, however, the pair noted that the definition of “small vessel” varied across the trials studied, with some vessels larger than 2.5 mm inappropriately included.

     

    Disclosures

    Windecker reported receiving institutional research grants from Biotronik, Abbott Vascular, Boston Scientific, Biosensors, Medtronic, Edwards Lifesciences, and St. Jude Medical; and speaking fees from AstraZeneca, Eli Lilly, Abbott Vascular, Biosensors, Biotronik, Boston Scientific, Medtronic, and Eli Lilly.

    Alfonso and García-Guimaraes declared no relevant conflicting interests.

     

    Source:

    JACC: Cardiovascular Interventions

    https://interventions.onlinejacc.org/article.aspx?articleid=2528942

    Siontis GCM, et al “Percutaneous coronary interventions for the treatment of stenoses in small coronary arteries: a network meta-analsis” JACC Cardiovasc Interv 2016; DOI: 10.1016/j.jcin.2016.03.025.

     

    JACC: Cardiovascular Interventions

    https://interventions.onlinejacc.org/article.aspx?articleid=2528086

    Alfonso F, et al “Optimal coronary interventions in small vessels: is size all that matters?” JACC Cardiovasc Interv 2016; DOI: 10.1016/j.jcin.2016.05.005.

     

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