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European Heart Journal Advance Access published online on January 28, 2005
European Heart Journal, doi:10.1093/eurheartj/ehi116
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European Heart Journal © The European Society of Cardiology 2005; all rights reserved

Clinical research

Is bare-metal stenting superior to balloon angioplasty for small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials

Pierfrancesco Agostoni 1*, Giuseppe G.L. Biondi-Zoccai 2, Gabriele L. Gasparini 3, Maurizio Anselmi 3, Giorgio Morando 3, Marco Turri 3, Antonio Abbate 4, Eugene P. McFadden 5, Corrado Vassanelli 3, Piero Zardini 3, Antonio Colombo 2, and Patrick W. Serruys 5

1 Department of Biomedical and Surgical Sciences, Section of Cardiology, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy; Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
2 S. Raffaele Hospital, ‘Vita e Salute’ University, University of Milan, Milan, Italy
3 Department of Biomedical and Surgical Sciences, Section of Cardiology, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy
4 Department of Medicine, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA, USA
5 Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands

* To whom correspondence should be addressed.
Pierfrancesco Agostoni, E-mail: agostonipf{at}genie.it


  Abstract

Aims To compare, by meta-analytical techniques, the clinical impact of bare-metal stenting vs. balloon angioplasty for the treatment of lesions in small coronary arteries.

Methods and results We included trials with random allocation and prospective comparison of angioplasty vs. stenting, reference vessel diameter <3 mm, and follow-up ≥6 months. Random effect odds ratios (OR) for death, myocardial infarction (MI), repeat revascularization (RR), and major adverse cardiac events (MACEs) were computed. In a pre-specified subgroup analysis, we compared stenting with optimal (post-procedural stenosis <20%) and suboptimal (>20%) angioplasty. Thirteen studies (4383 patients) were selected. No differences were found in terms of death and MI, while MACEs, mainly driven by RR, were significantly less common after stenting (17.6%) than after angioplasty (22.7%), OR 0.71 (0.57-0.90). Heterogeneity among trials was present. When considering only optimal angioplasty, MACE rates were homogeneously similar, 17.9 vs. 21.1%, OR 0.86 (0.66-1.11). If angioplasty were suboptimal, MACEs were significantly more common after angioplasty (24%) than after stenting (17.3%), OR 0.62 (0.44-0.88).

Conclusion Stenting is superior to balloon angioplasty for the treatment of small vessels, in particular after suboptimal angioplasty. However, MACE and RR rates remain high after stenting, and the advantage of stent over angioplasty is moderate. An optimal balloon angioplasty strategy (with provisional stenting) may achieve results not inferior to routine stenting.

Keywords: Meta-analysis; Stent; Balloon angioplasty; Small coronary arteries.
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