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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Coronary stenting versus balloon angioplasty in small vessels

A meta-analysis from 11 randomized studies

^* Division of Interventional Cardiology, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain

Manuscript received December 12, 2003; revised manuscript received January 9, 2004, accepted January 13, 2004.

^* Reprint requests and correspondence: Dr. Raúl Moreno, Cardiología Intervencionista, Instituto Cardiovascular, Hospital Clínico San Carlos, Martín Lagos, s/n, 28040 Madrid, Spain.
raulmorenog{at}terra.es

OBJECTIVES: A meta-analysis of 11 randomized trials was done to compare stenting versus balloon angioplasty (BA) in small coronary vessels.

BACKGROUND: Randomized studies on coronary stenting (CS) in small vessels have yielded controversial results.

METHODS: Eleven randomized trials on CS versus BA in small vessels, including angiographic re-evaluation at six months, were analyzed.

RESULTS: The BeStent (Medtronic Instent, Minneapolis, Minnesota) was used in four studies, the Multi-Link (Guidant, Advanced Cardiovascular Systems Inc., Santa Clara, California) in three trials, and the NIR (Boston Scientific Corp., Boston, Massachusetts), JoStent (Jomed International AB, Helsingborg, Sweden), Tenax (Biotronik, Berlin, Germany), and BioDivysio (Abbott Vascular Devices, Redwood City, California) in the remaining four trials. Overall, 3,541 patients were included (1,672 allocated to BA and 1,869 to stent). The rate of cross-over from balloon to stent in the pooled population was 19%, and unsuccessful stent deployment occurred in 2% of the patients allocated to stent. The pooled rates of restenosis were 25.8% and 34.2% in patients allocated to stent and balloon, respectively (p = 0.003) (risk ratio [RR] 0.77; 95% confidence interval [CI] 0.65 to 0.92). A smaller reference vessel diameter at baseline was associated with a higher risk reduction in the restenosis rate (y = –3.551 + 1.826 [x]; p = 0.012). Patients allocated to stent had lower rates of major adverse cardiac events (15.0% vs. 21.8%, p = 0.002; RR 0.70; 95% CI 0.57 to 0.87) and new target vessel revascularizations (12.5% vs. 17.0%, p = 0.004; RR 0.75, 95% CI 0.61 to 0.91).

CONCLUSIONS: Elective stenting is superior to provisional stenting in small coronary arteries. This benefit is more evident in smaller coronary arteries.

Abbreviations and Acronyms   BA = balloon angioplasty   BESMART = BEstent in SMall ARTeries   CHIVAS = Coronary Heart Disease Stenting In Small Vessels Versus Balloon Angioplasty Study   CI = confidence interval   COAST = heparin-COAted STents in small coronary arteries   COMPASS = Cilostazol Or Multi-link for Percutaneous transluminal coronary Angioplasty Small vessel Study   CS = coronary stenting   ISAR-SMART = Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries   ISAR-STEREO = Strut Thickness Effect on Restenosis Outcome   LASMAL = Latin America Small Vessel Randomized Study   MLD = minimum lumen diameter   RAP = Restenosis en Arterias Pequeñas   RR = risk ratio   RVD = reference vessel diameter   SISA = Stenting In Small Arteries   SISCA = Stent In Small Coronary Arteries   STRESS = Stent Restenosis Study

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