Drug-coated balloon versus drug-eluting stent in de novo small coronary vessel disease: A systematic review and meta-analysis

Unravelling the progress and potential of drug-eluting stents and drug-coated balloons in cardiological insurgencies

AIM

Coronary artery disease (CAD) is the leading cause of mortality. Though percutaneous transluminal angioplasty followed by stenting is still the default treatment of choice for revascularization of obstructive CAD, the high rate of restenosis compromises the outcomes of endovascular procedures. To overcome restenosis, drug-eluting stents (DES) and drug-coated balloons (DCB) are designed that release antiproliferative drugs like sirolimus, paclitaxel, everolimus, etc., over time to inhibit cell growth and proliferation. Our review aims to summarize the challenges and progress of DES/DCBs in clinical settings.

MATERIAL AND METHODS

The comprehensive review, search and selection encompasses in relevant articles through Google Scholar, Springer online, Cochrane library and PubMed that includes research articles, reviews, letters and communications, various viewpoints, meta-analyses, randomized trials and quasi-randomized trials. Several preclinical and clinical data have been included from National Institutes of Health and clinicaltrials.gov websites.

KEY FINDINGS

Challenges like delayed endothelialization, stent thrombosis (ST), and inflammation was prominent in first-generation DES. Second-generation DES with improved designs and drug coatings enhanced biocompatibility with fewer complications. Gradual absorption of bioresorbable DES over time mitigated long-term issues associated with permanent implants. Polymer-free DES addressed the inflammation concerns but still, they leave behind metallic stents in the vasculature. As an alternative therapeutic strategy, DCB were developed to minimize inflammation in the vessel. Although both DES and DCBs have shown considerable progress, challenges persist.

SIGNIFICANCE

This review illustrates the advancements in the designs, preparation technologies, biodegradable materials, and drugs used as well as challenges associated with DES and DCBs in clinical settings.

Drug-Coated Balloons for De Novo Coronary Artery Lesions: A Meta-Analysis of Randomized Clinical Trials

PURPOSE

Through meta-analysis, we aimed to assess the efficacy and safety of drug-coated balloons (DCB), compared with drug-eluting stents (DES) or uncoated devices, in the treatment of de novo coronary lesions.

MATERIALS AND METHODS

Only randomized controlled trials were included. The primary outcomes were late lumen loss (LLL), target lesion revascularization (TLR), and major adverse cardiac events (MACEs). Subgroup analyses were conducted based on clinical indications, whether DCBs were used with a systematic or bailout stent, and types of DESs.

RESULTS

The present meta-analysis demonstrated that DCBs elicit significantly lower incidences of TLR, MACE, and LLL, compared with uncoated devices, and similar incidences, compared with DESs, in the treatment of de novo coronary lesions. Subgroup analysis indicated that DCBs used with a bailout stent achieved lower incidences of binary restenosis and myocardial infarction, compared with uncoated devices, and provided less LLL than DESs. DCBs showed similar rates of TLR and MACE, with significantly less LLL, than DESs in treating de novo small-vessel diseases. The clinical efficacy of DCBs was similar to that of second-generation DES.

CONCLUSION

Overall, DCB is favored over bare metal stent alone in treating de novo coronary lesions. DCBs appear to be a promising alternative to DESs in the treatment of de novo coronary lesions.

Drug-coated balloon: an effective alternative to stent strategy in small-vessel coronary artery disease-a meta-analysis

Background

Small-vessel coronary artery disease (CAD) is frequently observed in coronary angiography and linked to a higher risk of lesion failure and restenosis. Currently, treatment of small vessels is not standardized while having drug-eluting stents (DES) or drug-coated balloons (DCBs) as possible strategies. We aimed to conduct a meta-analytic approach to assess the effectiveness of treatment strategies and outcomes for small-vessel CAD.

Methods

Comprehensive literature search was conducted using PubMed, Embase, MEDLINE, and Cochrane Library databases to identify studies reporting treatment strategies of small-vessel CAD with a reference diameter of ≤3.0 mm. Target lesion revascularization (TLR), target lesion thrombosis, all-cause death, myocardial infarction (MI), and major adverse cardiac events (MACE) were defined as clinical outcomes. Outcomes from single-arm and randomized studies based on measures by means of their corresponding 95% confidence intervals (CI) were compared using a meta-analytic approach. Statistical significance was assumed if CIs did not overlap.

Results

Thirty-seven eligible studies with a total of 31,835 patients with small-vessel CAD were included in the present analysis. Among those, 28,147 patients were treated with DES (24 studies) and 3,299 patients with DCB (18 studies). Common baseline characteristics were equally distributed in the different studies. TLR rate was 4% in both treatment strategies [0.04; 95% CI 0.03-0.05 (DES) vs. 0.03-0.07 (DCB)]. MI occurred in 3% of patients receiving DES and in 2% treated with DCB [0.03 (0.02-0.04) vs. 0.02 (0.01-0.03)]. All-cause mortality was 3% in the DES group [0.03 (0.02-0.05)] compared with 1% in the DCB group [0.01 (0.00-0.03)]. Approximately 9% of patients with DES developed MACE vs. 4% of patients with DCB [0.09 (0.07-0.10) vs. 0.04 (0.02-0.08)]. Meta-regression analysis did not show a significant impact of reference vessel diameter on outcomes.

Conclusion

This large meta-analytic approach demonstrates similar clinical and angiographic results between treatment strategies with DES and DCB in small-vessel CAD. Therefore, DES may be waived in small coronary arteries when PCI is performed with DCB.

Drug-Coated Balloon-Only Strategy for De Novo Coronary Artery Disease: A Meta-analysis of Randomized Clinical Trials

Backgrounds

Many clinical trials have demonstrated the value of drug-coated balloons (DCB) for in-stent restenosis. However, their role in de novo lesions is not well documented. The aim of this study is to evaluate the safety and efficacy of the DCB-only strategy compared to other percutaneous coronary intervention strategies for de novo coronary lesions.

Methods

The PubMed, Embase, Web of Science, and Cochrane Library Central Register of Controlled Trials (CENTRAL) electronic databases were searched for randomized controlled trials published up to May 6, 2023. The primary outcomes were major adverse cardiac events and late lumen loss.

Results

A total of eighteen trials with 3336 participants were included. Compared with drug-eluting stents, the DCB-only strategy was associated with a similar risk of major adverse cardiac events (risk ratio (RR) = 0.90; 95% confidence interval (CI): 0.59 to 1.37, P = 0.631) and a significant decrease in late lumen loss (standardized mean difference (SMD) = -0.29, 95% CI: -0.53 to -0.04, P = 0.021). This effect was consistent in subgroup analysis regardless of indication, follow-up time, drug-eluting stent type, and dual antiplatelet therapy duration. However, DCBs were inferior to DESs for minimum lumen diameter and percentage diameter stenosis. The DCB-only strategy showed significantly better outcomes for most endpoints compared to plain-old balloon angioplasty or bare metal stents.

Conclusions

Interventions with a DCB-only strategy are comparable to those of drug-eluting stents and superior to plain-old balloon angioplasty or bare metal stents for the treatment of selected de novo coronary lesions. Additional evidence is still warranted to confirm the value of DCB before widespread clinical utilization can be recommended.

Clinical characteristics, risk factors, and prognostic analyses of coronary small vessel disease: a retrospective cohort study of 986 patients

BACKGROUND AND AIMS

Coronary small vessel disease (CSVD) is often associated with significant percutaneous coronary intervention (PCI) related complications, complex lesions, complex PCI, and poor long-term prognosis. We designed this retrospective study to clarify the characteristics, risk factors, and prognostic analyses of CSVD in Chinese populations.

METHODS

A total of 986 patients who underwent coronary angiography and stent implantation at the First Affiliated Hospital of Zhejiang University School of Medicine were evaluated. Patients were grouped into CSVD or non-small vessel disease (non-CSVD) according to stent diameter. Clinical data, coronary angiography, and long-term follow-up were recorded. Multivariate logistic regression, the Kaplan-Meier method, Log-rank Test, and Cox regression model were used for statistical analysis.

RESULTS

Alcohol consumption (OR = 0.420, 95% CI: 0.299-0.588, P < 0.001) was implicated as a negative CSVD correlation factor. CSVD was more likely to be associated with multi-vessel lesions (79.2% vs. 49.4%, P < 0.001), bifurcation lesions (24.0% vs. 12.4%, P < 0.001), chronic total obstruction lesions (29.5% vs. 9.4%, P < 0.001), and long lesions (55.2% vs. 35.7%, P < 0.001), which reduced the efficacy of revascularization (70.1% vs. 85.1%, P < 0.001). In the follow-ups, cardiac death (2.3% vs. 0.4%, P = 0.008), stroke (1.9% vs. 0.3%, P = 0.007), target lesion revascularization (5.8% vs. 2.9%, P = 0.029), target vessel revascularization (6.8% vs. 3.4%, P = 0.016), and non-target vessel revascularization (7.8% vs. 4.0%, P = 0.012) were all substantially higher in CSVD patients. Troponin I level (OR = 1.008, 95% CI: 1.004-1.012, P < 0.001), complete revascularization (OR = 0.292, 95% CI: 0.160-0.531, P < 0.001), and aspirin administration (OR = 0.041, 95% CI: 0.013-0.131, P < 0.001) were independent predictors of MACE events of all patients.

CONCLUSION

Compared to non-CSVD, CSVD was associated with more complex lesions, had worse revascularization efficacy, and a poorer prognosis.

Clinical outcomes of percutaneous coronary intervention for de novo lesions in small coronary arteries: A systematic review and network meta-analysis

Background

Percutaneous coronary intervention (PCI) has a well-established role in revascularization for coronary artery disease. We performed network meta-analysis to provide evidence on optimal intervention strategies for de novo lesions in small coronary arteries.

Materials and methods

Enrolled studies were randomized clinical trials that compared different intervention strategies [balloon angioplasty (BA), biolimus-coated balloon (BCB), bare-metal stent (BMS), new-generation drug-eluting stent (New-DES), older generation sirolimus-eluting stent (Old-SES), paclitaxel-coated balloon (PCB), and paclitaxel-eluting stent (PES)] for de novo lesions in small coronary arteries. The primary outcome was major adverse cardiac events (MACE).

Results

A total of 23 randomized clinical trials comparing seven intervention devices were analyzed. In terms of the primary outcome, New-DES was the intervention device with the best efficacy [surface under the cumulative ranking curve (SUCRA), 89.1%; mean rank, 1.7], and the Old-SES [risk ratio (RR), 1.09; 95% confidence interval (CI), 0.45–2.64] and PCB (RR, 1.40; 95% CI, 0.72–2.74) secondary to New-DES, but there was no statistically significant difference between these three intervention devices. All DES and PCB were superior to BMS and BA for MACE in both primary and sensitivity analysis. For secondary outcomes, there was no association between all-cause mortality and myocardial infarction (MI) with any intervention strategy, and additionally, the findings of target lesion revascularization (TLR) were similar to the primary outcomes.

Conclusion

Paclitaxel-coated balloon yielded similar outcomes to New-DES for de novo lesions in small coronary arteries. Therefore, this network meta-analysis may provide potential support for PCB as a feasible, effective, and safe alternative intervention strategy for the revascularization of small coronary arteries.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/#recordDetails], identifier [CRD42022338433].

The comparative short-term efficacy and safety of drug-coated balloon vs. drug-eluting stent for treating small-vessel coronary artery lesions in diabetic patients

Purpose

This meta-analysis aimed to explore the comparative short-term efficacy and safety of drug-coated balloon (DCB) vs. drug-eluting stent (DES) for treating small-vessel coronary artery lesions in diabetic patients.

Methods

We searched PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) for retrieving relevant studies regarding the comparison of DCB with DES in treating small-vessel coronary artery lesions in diabetic patients until May 31, 2022. Two independent authors screened study, extracted data, and assessed methodological quality. Then, the meta-analysis was conducted using RevMan software, version 5.4.

Results

We included 6 studies with 847 patients in this meta-analysis. Pooled results showed that DCB was associated with fewer major adverse cardiac events (MACE) [RR, 0.60; 95% confidence interval (CI), 0.39-0.93; p = 0.02], myocardial infarction (MI) (RR, 0.42; 95% CI, 0.19-0.94; p = 0.03), target lesion revascularization (TLR) (RR, 0.24; 95% CI, 0.08-0.69; p < 0.001), target vessel revascularization (TVR) (RR, 0.33; 95% CI, 0.18-0.63; p < 0.001), binary restenosis (RR, 0.27; 95% CI, 0.11-0.68; p = 0.005), and late lumen loss (LLL) [mean difference (MD), -0.31; 95% CI, -0.36 to -0.27; p < 0.001], but was comparable technique success rate, death, minimal lumen diameter (MLD), and net lumen gain (NLG) to DES. There was no difference in long-term outcomes between these two techniques.

Conclusions

This meta-analysis shows that DCB is better than DES in the short-term therapeutic efficacy and safety of small-vessel coronary artery lesions in diabetic patients. However, more studies are required to validate our findings and investigate the long-term effects and safety of DCB.

Drug-Coated Balloon vs. Stent for de novo Non-small Coronary Artery Disease: A Systematic Review and Meta-Analysis

Introduction: Drug-coated balloon (DCB) has been an attractive option in de novo vessels. A systematic review and meta-analysis were conducted to evaluate the efficacy and safety of DCB vs. stent for treating de novo lesions in non-small vessels.

Methods: Studies in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched (from their commencement to March 2021). This meta-analysis was performed by Review Manager 5.3.

Results: A total of 3 random controlled trials (RCTs) with 255 patients and 2 observational studies (OS) with 265 patients were included in this meta-analysis following our inclusion criteria. It could be observed that DCB presented no significant difference in cardiac death (CD) (RR 0.33, 95% CI [0.01, 8.29], p = 0.50 in OS), myocardial infarction (MI) (RR 0.49, 95% CI [0.09, 2.50], p = 0.39 in RCT), target lesion revascularization (TLR) (RR 0.64, 95% CI [0.19, 2.18], p = 0.47 in RCT) (RR 1.72, 95% CI [0.56, 5.26], p = 0.34 in OS), and late lumen loss (LLL) (SMD −0.48, 95% CI [−1.32, 0.36], p = 0.26 in RCT) for de novo non-small coronary artery disease (CAD) compared with stents, whereas minimal lumen diameter (MLD) including MLD1 (SMD −0.67, 95% CI [−0.92 −0.42], p < 0.00001 in RCT) and MLD2 (SMD −0.36, 95% CI [−0.61 −0.11], p = 0.004 in RCT) was smaller in DCB group.

Conclusion: This systematic review showed that DCB might provide a promising way on de novo non-small coronary artery disease compared with stents. However, more RCTs are still needed to further prove the benefits of the DCB strategy.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Drug-Coated Balloon versus Drug-Eluting Stent in Patients with Small-Vessel Coronary Artery Disease: A Meta-Analysis of Randomized Controlled Trials

Background

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) of small-vessel coronary artery disease (SVD) is related to an increased risk of in-stent restenosis (ISR) and stent thrombosis (ST). The application of the drug-coated balloon (DCB) for patients with SVD remains controversial.

Objectives

Assess the outcomes of DCB in the treatment of SVD compared with DES in patients with SVD.

Methods

A meta-analysis of randomized controlled trials (RCTs) published up to June 2020, reporting the outcomes of DCB versus DES in the treatment of SVD, was performed.

Results

Four RCTs with 1227 patients were included. The results indicated that DCB was associated with the decreased risk for myocardial infarction (MI) compared with the DES, but the difference showed no significance (OR 0.50, 95% CI 0.24-1.03, P=0.06). And, there was no significant difference in death (OR 0.76, 95% CI 0.17-3.43, P=0.72), cardiac death (OR 1.92, 95% CI 0.74-4.98, P=0.18), target vessel revascularization (TVR) (OR 0.81, 95% CI 0.51-1.28, P=0.36), target lesion revascularization (TLR) (OR 1.29, 95% CI 0.66-2.52, P=0.46), and major adverse cardiac events (MACE) (OR 0.92, 95% CI 0.61-1.38, P=0.69) between the DCB group and DES group.

Conclusion

Compared with DES, DCB was associated with a decreased risk of MI among patients with SVD, but the difference showed no significance. The application of DCB in SVD is associated with comparable outcomes of death, TVR, and MACE when compared with DES.

Three-year outcome with drug-coated balloon percutaneous coronary intervention in coronary Takayasu arteritis: A case review

We describe the first long-term follow-up of a young patient with active Takayasu arteritis who presented with an acute coronary syndrome, treated endovascularly with percutaneous coronary intervention without stenting. A drug-coated balloon was used with high-resolution coronary imaging guidance in the form of optical coherence tomography on a critical ostial left anterior descending coronary artery lesion. A repeat procedure was undertaken after 4 months confirming a durable coronary angioplasty result and the patient remained symptom-free beyond 3 years. Coronary stenting in this population is associated with early and aggressive stent failure. Hence, this is an innovative approach. We believe that the stent, regardless of whether it is first, second or subsequent generation, leaves a permanent foreign body within the vasculature that becomes the seed for inflammatory reactions, resulting in recurrent in-stent restenotic fibrosis irrespective of concurrent immunotherapy or the degree of disease activity.

Drug-Eluting Stents and Balloons-Materials, Structure Designs, and Coating Techniques: A Review

Controlled drug delivery is a matter of interest to numerous scientists from various domains, as well as an essential issue for society as a whole. In the treatment of many diseases, it is crucial to control the dosing of a drug for a long time and thus maintain its optimal concentration in the tissue. Heart diseases are particularly important in this aspect. One such disease is an obstructive arterial disease affecting millions of people around the world. In recent years, stents and balloon catheters have reached a significant position in the treatment of this condition. Balloon catheters are also successfully used to manage tear ducts, paranasal sinuses, or salivary glands disorders. Modern technology is continually striving to improve the results of previous generations of stents and balloon catheters by refining their design, structure, and constituent materials. These advances result in the development of both successive models of drug-eluting stents (DES) and drug-eluting balloons (DEB). This paper presents milestones in the development of DES and DEB, which are a significant option in the treatment of coronary artery diseases. This report reviews the works related to achievements in construction designs and materials, as well as preparation technologies, of DES and DEB. Special attention was paid to the polymeric biodegradable materials used in the production of the above-mentioned devices. Information was also collected on the various methods of producing drug release coatings and their effectiveness in releasing the active substance.

Long term outcome after treatment of de novo coronary artery lesions using three different drug coated balloons

OBJECTIVE

To evaluate the long-term efficacy of three currently available drug coated balloons (DCB) for the treatment of de-novo coronary lesions.

METHODS

This was a retrospective analysis of prospectively collected data from the Swedish Coronary Angiography and Angioplasty Registry. Between 2009 and 2017, three currently available DCB brands used in the treatment of de novo lesions were included. Outcomes were clinically driven restenosis and target lesion thrombosis (TLT) (per device) and major adverse cardiac events (MACE) including death, myocardial infarction or target vessel revascularization (per patient) at 4 years. Multivariable Cox regression models were used to adjust for differences.

RESULTS

We included 6715 lesions treated with DCBs, 4483 SeQuent® Please (S-DCB), 1071 IN.PACT Falcon (I-DCB) and 1161 Pantera® Lux (P-DCB), in 5670 patients. The mean DCB diameter was 2.4 mm. Bailout stenting occurred in 6.7% of lesions. Angiographic success was 98.5%. The overall cumulative rate of restenosis was 5.5% (299 events). The risk for reported restenosis did not significantly differ between I-DCB vs S-DCB, adjusted hazard ratio (aHR) 0.96; 95% confidence interval (CI) 0.69-1.34, P-DCB vs S-DCB aHR 0.88; 95% CI 0.63-1.23 and I-DCB vs P-DCB aHR 1.10; 95% CI 0.72-1.68. The cumulative risk for TLT was 0.8% in all three DCBs. The risk for MACE or individual components of MACE did not differ between the three patient-groups.

CONCLUSION

In de novo coronary lesions, we found comparable long-term efficacy with three currently available DCB brands. DCB angioplasty was feasible with low risk for long-term restenosis and TLT.

Drug-Coated balloons vs drug-eluting stents for the treatment of small coronary artery disease: A meta-analysis of randomized trials

OBJECTIVES AND BACKGROUND

There is conflicting evidence about the effects of drug-coated balloons (DCB) compared with drug-eluting stents (DES) in patients with native small vessel coronary artery disease (CAD).

METHODS

The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases and main international conference proceedings were searched for randomized controlled trials (RCT) comparing DCB versus DES in patients with native small vessel CAD. Data were pooled by meta-analysis using a random-effects model. The primary endpoint was target vessel revascularization (TVR). Secondary clinical endpoints were: myocardial infarction (MI), target lesion revascularization (TLR), all-cause death, cardiac death, and stent thrombosis or target vessel thrombosis. Secondary angiographic outcomes were: in-segment restenosis, in-segment percentage-diameter stenosis, in-segment late lumen loss, in-segment net luminal gain, and in-segment minimal lumen diameter.

RESULTS

Five trials enrolling 1,459 patients were included. Mean clinical follow-up was 10.2 months. The use of DCB, compared with DES, was associated with similar risk of TVR (odds ratio [OR]: 0.97; 95% confidence interval [CI] 0.56 to 1.68; p = .92), TLR (OR: 1.74; 95% CI: 0.57 to 5.28; p = .33), all-cause death (OR: 1.03; 95% CI: 0.14 to 7.48; p = .98), with a trend toward a lower risk of MI (OR: 0.49; 95% CI: 0.23 to 1.03; p = .06), and with significant lower risk of vessel thrombosis (OR: 0.12; 95% CI: 0.01 to 0.94; p = .04). DCB use was associated with similar risk of angiographic restenosis (OR: 1.12; 95% CI 0.69 to 1.84; p = .64), comparable late luminal loss (standardized mean difference (SMD): -0.18; 95% CI: -0.39 to 0.03; p = .09), while leading to significant higher percentage diameter stenosis (SMD: 0.27; 95% CI 0.12 to 0.41; p < .01) and smaller minimal luminal diameter (SMD: -0.52; 95% CI: -0.86 to -0.18; p = .003).

CONCLUSION

Compared with DES, the use of DCB for the treatment of native small vessel CAD is associated with similar TVR and restenosis and reduces the risk of vessel thrombosis, although DES implantation yields slightly better angiographic surrogate endpoints.

Clinical and Angiographic Outcomes With Drug-Coated Balloons for De Novo Coronary Lesions: A Meta-Analysis of Randomized Clinical Trials

Background

The role of drug‐coated balloons (DCBs) in the treatment of de novo coronary lesions is not well established.

Methods and Results

Electronic databases and major conference proceedings were searched for randomized controlled trials that compared DCBs with stents or angioplasty for de novo coronary lesions. The primary outcome was target lesion revascularization. Summary estimates were conducted using random‐effects analysis complemented by several subgroup and sensitivity analyses. A total of 14 randomized controlled trials with 2483 patients were included. At a mean follow up of 12 months, DCBs were associated with no difference in the incidence of target lesion revascularization as compared with alternative strategies (risk ratio [RR], 0.79; 95% CI, 0.35–1.76). There was no difference in treatment effect based on the indication (ie, small‐vessel disease, myocardial infarction, bifurcation, or high bleeding risk) (P_interaction=0.22). DCBs were associated with lower target lesion revascularization compared with bare metal stents and similar target lesion revascularization compared with drug‐eluting stents (P_interaction=0.03). There was no difference between DCBs and control in terms of major adverse cardiac events, vessel thrombosis, or cardiovascular mortality. However, DCBs were associated with a lower incidence of myocardial infarction (RR, 0.48; 95% CI, 0.25–0.90) and all‐cause mortality (RR, 0.45; 95% CI, 0.22–0.94).

Conclusions

In patients with de novo coronary lesions, use of DCBs was associated with comparable clinical outcomes irrespective of the indication or comparator device. DCBs had a similar rate of target lesion revascularization compared with drug‐eluting stents. A randomized trial powered for clinical outcomes and evaluating the role of DCBs for all‐comers is warranted.