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Drug-coated balloons versus drug-eluting stents in patients with small coronary artery disease: an updated meta-analysis

BMC Cardiovascular Disorders volume 25, Article number: 339 (2025) Cite this article

Abstract

Background

Drug-coated balloons (DCB) have promising results in the management of large coronary artery lesions (CAD), still their role in treating small CAD is not well established. We aimed to provide a comprehensive appraisal of the efficacy and safety of DCBs in patients with small CAD.

Methods

We searched PubMed, Scopus, web of science, Ovid, and Cochrane Central from inception until 30 March, 2023. We included all relevant studies that compared DCB versus drug-eluting stents (DES) in small CAD patients undergoing PCI. We reported clinical outcomes as MACE, all-cause death, cardiac death, MI, TLR, TVR, and stent thrombosis, while angiographic outcomes were late lumen loss (LLL), mean lumen diameter (MLD), net luminal gain (NLG), and in-segment binary restenosis.

Results

Twenty studies comprising 18,469 patients were included in this meta-analysis. The incidence rate of MACE was 9.4% in the DCB group compared to 9.9% in the DES group, without a significant difference in the risk of MACE (OR = 0.97, 95% CI: 0.77 to 1.22, p = 0.78). Moreover, DCB significantly decreased MLD and NLG compared to DES, with the following values, respectively (MD= -0.19, 95% CI: -0.32 to -0.06, p < 0.001, and MD -0.21, 95% CI: -0.40 to -0.01, p = 0.04). On the other hand, DCB was associated with higher odds in the risk of in-segment binary restenosis (OR 1.66, 95% CI: 1.03 to 2.68, p = 0.04).

Conclusion

DCB is an alternative approach to DES in the management of small CAD and should be validated in daily clinical practice.

Prospero registration

CRD42023413068.

Peer Review reports

Introduction

The primary approach for treating coronary artery disease (CAD) involves drug-eluting stents (DESs) of second generations. However, drug-coated balloons (DCBs) offer a new and innovative alternative for certain patients, such as those with in-stent restenosis, a higher risk of bleeding, or large vessel CAD [1, 2].

DCBs consist of balloons coated with a specific drug in a specific matrix. Once the balloon is inflated, the drug is quickly embedded into the vessel wall, providing its anti-proliferative effect. DCBs can be used, also, in the coronary vasculature as long as the preparation of lesion does not lead to major complications as leaving residual stenosis greater than 30% or lead to flow-limiting dissections, and there is no inhibition of drug transfer due to the presence of a large intravascular thrombus [3, 4]. The primary drawback of the DCB-only strategy is the lack of intravascular foreign material, which could lead to severe complications as stent thrombosis. Other advantages include the need for only short-term dual antiplatelet therapy (DAPT) of four weeks after DCB and the potential long-term positive remodeling effect on the treated vessel associated with paclitaxel [3, 4].

Regarding DCB’s role concerning different coronary artery disease diameters, Yu and colleagues found that treating large coronary de novo lesions using DCB alone was safe and effective [5]. For small vessel disease, both the Balloon Elution and Late Loss Optimization (BELLO) study and the Basel Kosten Effektivitäts Trial-Drug-Coated Balloons versus Drug-eluting Stents in Small Vessel Interventions (BASKET-SMALL) trial showed low rates of major adverse cardiac events (MACE) at the one-year follow-up [6, 7]. Additionally, a previous report from the RESTORE small vessel disease (SVD) China study indicated that DCBs were non-inferior to DES [8].

DES is associated with an improvement in clinical outcomes of patients with large CAD, despite the improved rates of clinical outcomes, the amount of stent length remains unchanged with higher rates of late adverse events [4, 5]. Moreover, the use of DES in patients with small de novo CAD lesions was associated with higher risk of restenosis and stent thrombus. Conflict data between the role of DCB and DES in small lesions were reported.

Li et al., in their meta-analysis, found that the use of DCB is comparable to the DES in achieving favorable outcomes, including a reduced risk of nonfatal myocardial infarction [9]. As such, it may be considered a highly recommended treatment approach for patients with de novo small coronary artery vessel disease.

From the aforementioned literature, DCB showed promising results in CAD, but their role in de novo small CAD needs stronger evidence to be established in our everyday clinical practice, and yet no comprehensive pooled analysis was established. So, We aimed to provide a more comprehensive and quantitative assessment of the efficacy and safety of DCB compared with DES in de novo small vessel CAD.

Methods

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in the current meta-analysis [10], and followed the guidelines of the Cochrane Handbook of Systematic Reviews and Meta-analysis of Interventions. The study was registered on PROSPERO CRD42023413068.

Eligibility criteria

We included all the relevant studies, RCTs or observational studies, addressing patients of de novo small coronary artery disease undergoing PCI treated with DCB as the intervention group and the DES as the control group, and reported the outcomes of interest in an intention-to-treat analysis. we excluded the animal studies, conference abstracts, and unpublished data. We did not use the English filter, so any foreign language was considered in our inclusion criteria.

Primary and secondary outcomes

The primary outcome of interest was the incidence of MACE. The definitions reported by each author are illustrated in supplementary Table 1. While the secondary outcomes of interest were the incidence of myocardial infarction (MI), target lesion revascularization (TLR), cardiac death, all-cause death, target vessel revascularization (TVR), stent thrombosis, in-segment binary restenosis, and angiographic assessment as minimum lumen diameter (MLD), late lumen loss (LLL), and net lumen gain (NLG).

Literature search and screening

An electronic search on Scopus, PubMed, Web of Science, Ovid, and Cochrane Central from inception until March 30th, 2023, was carried out using the following search strategy: (“drug-coated balloon” OR “DCBs” OR “drug coated balloons”) AND (“drug-eluting stent” OR “DES” OR “drug eluting stents” OR “stent”) AND (“small-vessel coronary artery” OR “de novo small coronary vessel disease*” OR “de novo small coronary artery lesion*”) AND (“PCI” OR “Percutaneous Coronary Intervention”). Any duplicates were removed using EndNote. Moreover, all included studies were retrieved manually for additional studies. The results were screened in a two-step wise; the first was title and abstract screening then a full-text screening of the relevant studies was done.

Data extraction

We used a specified data extraction sheet to include the following items: (1) Characteristics of the population of included studies, (2) Characteristics of the included studies, (3) Assessment of Risk of bias domains, (4) Outcomes of interests.

Synthesis of results

In case of multiple time points reported by each study, we considered the outcomes of the last follow-up point as our long-term follow-up. The number of events and the total of sample size included were pooled as odds ratio (OR) and its 95% confidence interval (CI) for dichotomous outcomes using the DerSimonian-Laird random-effect model. Moreover, the mean difference (MD) and its 95% CI were pooled for continuous outcomes in the DerSimonian-Laird random-effect model. All analyses were computed using Stata MP 17 for Mac.

Assessment of heterogeneity

We used the chi-square test using the following equation: I2 = Q-dfQx100% to assess the statistical heterogeneity reported among studies. The P-value of less than 0.05 was considered a significant heterogeneity. High heterogeneity was defined as I-square values ≥ 50%. When there is significant heterogeneity, the leave-one-out sensitivity analysis model was used to resolve reported heterogeneity. Galbraith plot was used to detect any heterogeneity across studies.

Quality assessment

The quality of included clinical trials was assessed according to the Cochrane Risk of Bias 2 (ROB-2) tool for RCTs that involves the following five domains: selection bias via the randomization process, performance bias via the deviation from the intended interventions, detection bias via the outcome measurement, attrition bias via any missing outcome data, reporting bias via the selection of reported results and any other potential source of bias.

The authors’ decision is classified as Low risk of bias”, ‘Some concerns”, or ‘High risk of bias”. We used funnel plots to detect the publication bias. Moreover, evidence of publication bias was assessed by Egger’s regression test.

We performed a Trial Sequential Analysis (TSA) to assess the robustness of the pooled evidence from studied outcomes as to the cumulative analysis of the included trials; there is an increased possibility of multiple statistical errors as type 1 and type 2 errors. When the pooled Z-line on the curve crosses the reference boundary and boundary of pooled analysis, this is an indication of no further trials are required, and the evidence is conclusive and sufficient. However, if the pooled Z-line on the curve does not cross any boundary, then the evidence is not sufficient to draw a conclusion and more studies are still needed. In the current meta-analysis, we declared a 0.05 value as our alpha error, and a beta error of 0.2 corresponding to 80% power. We calculated the mean difference in this meta-analysis to obtain the sample size needed for TSA.

Results

Literature search

Our literature search included 318 records. After title and abstract screening, 30 articles were eligible for consideration as full-text screening. A total of 20 studies with 4 extended studies were included in the study. The process of study selection is shown in the PRISMA flow diagram, as shown in Fig. 1.

Fig. 1
figure 1

PRISMA flow diagram

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Characteristics of included studies

All studies enrolled 18,469 patients from 20 studies and 4 extended studies [5,6,7], [11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27]. Of the 20 included studies of which 13 studies were RCTs and 7 studies were observational. The summary and baseline of the included studies are summarized in Table 1.

Table 1 The summary and baseline of all included studies
Full size table

Risk of bias assessment

Regarding risk of bias assessment of RCTs, seven studies showed an overall some concerns, mainly due to lack of information of the randomization process, as shown in Fig. 2.

Fig. 2
figure 2

Risk of bias assessment tool-2 (ROB-2) for RCTs

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As for risk of bias assessment of observational studies, All the seven studies were truly representative of the included patients. In addition, the control group was selected from the same community. Also, the two groups included in all studies were comparable in all studies. Some studies (Tasai 2022, Silverio 2020, and Giannini 2017) achieved comparability through a propensity matching model. The follow-up periods were adequate in all studies. In conclusion, the overall quality of all the studies is good. The risk of bias summary is illustrated in Table 2.

Table 2 NOS scale for observational studies
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Clinical outcomes

MACE

The incidence of MACE was reported in 16 studies, of which the event rate in the DCB group was 9.4% (158 of 1,677), while it was 9.9% (185 of 1855) in the DES group. The pooled OR did not favour DCB over DES in MACE (OR = 0.97, 95% CI [0.77 to 1.22], p = 0.78; I2 = 0%, p = 0.43), as shown in Fig. 3. A pooled analysis of a composite of cardiac death, MI, and TLR showed that the pooled OR did not favour DCB over DES (OR = 1.11, 95% CI [0.76 to 1.63], p = 0.60), as shown in Supplementary Fig. 1.

Fig. 3
figure 3

Forest plot of MACE

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A subgroup analysis was performed on study designs, of which the pooled analysis showed no significant difference in the two subgroups (OR = 0.94, 95% CI [0.65 to 1.37], p = 0.75; I2 = 0%, p = 0.99 for observational studies, and (OR = 0.99, 95% CI [0.70 to 1.39], p = 0.93; I2 = 0%, p = 0.14 for RCTs), as shown in Supplementary Fig. 2.

We further performed another subgroup analysis on the intervention, in which the pooled analysis did not favour any of the two interventions in studies subgroups (OR = 1.78, 95% CI [0.70 to 4.50], p = 0.22, 0.88, 95% CI [0.69 to 1.13], p = 0.32) for the DCB plus BMS vs. DES, and DCB vs. DES, respectively, as shown in Supplementary Fig. 3.

Galbraith plot and funnel plot were assessed, and by inspection, only one study was visualized out of the 95% CI of the precision are, indicating their heterogeneity from other studies, however the funnel plot was symmetry and no other studies were need to achieve stability suggesting that no possible publication bias found, as shown in Figs. 4 and 5.

Fig. 4
figure 4

Galbraith plot of MACE

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Fig. 5
figure 5

Funnel plot of MACE (p = 0.186)

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We performed a trial sequential analysis (TSA) on 16 studies that assessment MACE of which the cumulative Z-line on the curve did not cross either the conventional boundaries of benefit nor the trial sequential monitoring boundaries for any interventions, suggesting that DCB is not-inferior to DES, and further large volume RCTs should be carried out to validate our results, as shown in Fig. 6.

Fig. 6
figure 6

A trial sequential analysis (TSA) for 16 studies assessing the incidence of MACE of which the cumulative Z-line on the curve did not cross either the conventional boundaries of benefit nor the trial sequential monitoring boundaries for any interventions, suggesting that DCB is not-inferior to DES, and further large volume RCTs should be carried out to validate our results. A diversity-adjusted required information size of 5,478 patients was calculated using an alpha error of 0.05, a beta error of 0.20 (power 80%), and a control event proportion of 9.9%, as calculated from the control group in this meta-analysis

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Secondary clinical outcomes

The pooled analysis of all-cause death reported by 16 studies (n = 17,983 patients) showed that DCB was non-inferior to DES (OR 0.98, 95% CI [0.69 to 1.40], p = 0.93; the pooled studies were homogenous (p = 0.93; I2 = 9%), as shown in Supplementary Fig. 4. Also, the pooled analysis of cardiac death reported by eight studies (n = 1,108 patients) showed that DCB was non-inferior to DES (OR 1.51, 95% CI [0.78 to 2.93], p = 0.22; the pooled studies were homogenous (p = 0.92; I2 = 0%), as shown in Supplementary Fig. 5.

Regarding MI, the pooled analysis of 19 studies (n = 18,409 patients) showed that DCB was non-inferior to DES (OR 1.07, 95% CI [0.89 to 1.30], p = 0.47; the pooled studies were homogenous (p = 0.54; I2 = 0%), as shown in Supplementary Fig. 6.

As to TLR and TVR, the pooled analysis of 18 studies (n = 17,601 patients) and 11 studies (n = 2,346 patients), respectively did not favor either of the two interventions (OR 1.04, 95% CI [0.74 to 1.48], p = 0.82; and OR 1.00, 95% CI [0.64 to 1.55], p = 0.99), respectively. The pooled studies were homogenous for TLR and little heterogenous for TVR with the following values, respectively (p = 0.25; I2 = 17.34%, and p = 0.09; I2 = 39.10%), as shown in Supplementary Figs. 7, 8.

We performed a sensitivity analysis called Leaveoneout for TVR, and no single study had a disproportional effect on the pooled OR, which varied from 0.86 by excluding Liistro et al. and by 1.11 when excluding Zheng et al., as shown in Supplementary Fig. 9.

Regarding stent thrombosis, the pooled analysis of 12 studies (n = 2,788 patients) showed that DCB was non-inferior to DES (OR 0.87, 95% CI [0.46 to 1.65], p = 0.67; the pooled studies were homogenous (P = 0.96; I2 = 0%), as shown in Supplementary Fig. 10.

Angiographic outcomes

As to MLD and NLG, the pooled analysis of 15 studies (n = 2,195 patients) and eight studies (n = 2,195 patients), respectively showed that DCB was superior to DES with the following values, respectively (MD -0.19, 95% CI [-0.32 to -0.06], p < 0.001, and MD -0.21, 95% CI [-0.40 to -0.01], p = 0.04), respectively, as shown in Figs. 7 and 8. The pooled studies for MLD and NLG were heterogenous with the following values (p < 0.001; I2 = 90.96%, and p < 0.001; I2 = 95.11%), respectively, as shown in Figs. 7 and 8.

Fig. 7
figure 7

Forest plot of MLD

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Fig. 8
figure 8

Forest plot of NLG

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We performed a sensitivity analysis called Leaveoneout for MLD, and no single study had a disproportional effect on the overall MD. However, in NLG, only two studies Giannini et al., and Zhou et al., when excluded, the overall MD remains significant in favor of DCB, as shown in Supplementary Figs. 11, 12.

The pooled analysis of the LLL reported by 13 studies (n = 1,936 patients) did not favor either of the two interventions (MD -0.06, 95% CI [-0.22 to 0.09], p = 0.43; the pooled studies were heterogenous (P = 0.01; I2 = 96.82%), as shown in Supplementary Fig. 13.

However, when we performed a sensitivity analysis upon excluding Liistro et al., the pooled analysis favored DCB group over DES group (MD -0.12, 95% CI [-0.23 to -0.01], p = 0.03), as shown in Supplementary Fig. 14.

On the other hand, the pooled analysis of the in-segment binary restenosis reported by eight studies (n = 15,841 patients) favored the DES group over the DCB group (OR 1.66, 95% CI [1.03 to 2.68], p = 0.04; the pooled studies were heterogenous (p = 0.05; I2 = 49.92%), as shown in Supplementary Fig. 15. However, when we performed a sensitivity analysis upon excluding Liistro et al., the pooled analysis did not show any significant difference between the two interventions (OR 1.49, 95% CI [0.95 to 2.33], p = 0.08), as shown in Supplementary Fig. 16.

Discussion

Our study systematically retrieved all studies comparing DCB intervention to DES intervention for the management of patients with small CAD including 20 trials entered the quantitative analysis comprising 18,469 patients. Our pooled analysis did not favor DCB, when compared to DES, regarding MACE, and further subgroup analyses based on the type of study, language, and the indication of the interventions, yet, did not favor DCB over DES. Moreover, there was no significant difference in terms of all-cause death, cardiac death, MI, TLR, stent thrombosis, or TVR between the two studied groups. In terms of in-segment binary restenosis, DCB had higher odds, however; when excluding Liistro et al. 2013, the pooled analysis showed non-inferiority with no superiority of DES over the DCB. As to angiographic outcomes, our pooled analysis favored DCB intervention compared to DES according to MLD and NLG. Regarding LLL, the pooled analysis did not favor DCB or DES, however; when excluding Liistro et al. 2013, the pooled analysis favored DCB.

PCI, for small CAD, is still challenging due to the increased risk of technical complications, acute vessel closure, and the necessity for multiple revascularization procedures [28, 29]. DES is still the standard treatment approach for PCI [30]. However, DES implantation can cause damage to the arterial wall, triggering a cascade of cellular proliferation and migration that leads to neointimal hyperplasia [31]. In contrast, DCB can administer antiproliferative drugs directly into the vessel wall without the need for metal struts, which can inhibit endothelial proliferation and adverse remodeling [32]. Therefore, theoretically, DCB implantation is a more effective treatment option for small-vessel coronary artery lesions compared to DES.

The current disease guidelines and consensus do not offer an optimal treatment selection for patients with de novo CAD. One potential solution is the use of DCB, which has shown promising outcomes. However, it has certain drawbacks such as a shorter balloon inflation time and concerns about its impact on blood flow, which raises questions about whether it delivers enough medication to the vessel wall and if it can sustain drug concentration at levels comparable to those achieved with DES [33]. Furthermore, there are cases where bailout stenting is necessary, which is an important strategy in situations where angiography results are suboptimal, significant dissection occurs, or there is acute elastic recoil following DCB treatment, which in turn makes it difficult to directly compare the effectiveness of DCB versus DES. Several studies [9, 34]– [37] have recently used meta-analytic techniques to compare the safety and effectiveness of DCB versus DES for treating de novo lesions in small-vessel coronary disease.

One such meta-analysis by Li et al., [9] found that DCB was not inferior to DES and produced positive outcomes in terms of non-fatal MI, while being comparable to DES in terms of TLR. Therefore, it is suggested that DCB can be a recommended treatment strategy for patients with de novo small-vessel coronary artery disease. However, their results were in line with our results regarding TLR, but not for MI; also, they had numerous falls as (1) assessment of non-fetal MI, not all MI; this could be a source of bias due to the higher incidence of fetal MI in DCB compared to DES, (2) their included studies used different device types or generations that could impact the overall results, (3) the follow-up reported in their studies were short.

Another meta-analysis by Megaly et al., [38] found that DCB decreased LLL compared to DES and a comparable risk of MACE, death, TLR, and TVR in both interventions. Their results were in line with our results regarding LLL, and other clinical outcomes. Moreover, another meta-analysis by Abdelaziz et al., [39] found that DCB was not inferior to DES in terms of clinical and angiographic outcomes in patients with AMI, highlighting the necessity of DCB as an alternative feasibility strategy in AMI patients.

Morever, when Li et al., [35] compared DCB to DES in patients with DM and small vessel CAD, they found that DCB did not show superiority compared to DES in terms of MLD and NLG. Moreover, DCB had a lower probability of MACE, LLL, and binary restenosis. Additional analysis indicated that DCB resulted in fewer MI, TLR, and TVR occurrences than DES, while having a death rate comparable to DES. However, their results are in line with our results regarding LLL, we did not find a significant difference in terms of MACE, MI, TLR, and TVR, and on the other hand; we found DCB had higher odds, when compared to DES. Some limitations of their study should be addressed, such as the short follow-up periods reported in their included studies, the limited number of studies in each outcome reported, and the significant heterogeneity found in some reported outcomes, which was not solved via a sensitivity analysis restricting to the limited included studies.

Additionally, in align with our results, a recent network meta-analysis addressing the efficacy of endovascular approaches as DCB and DES in peripheral artery diseases as femoropopliteal (FP) and infrapopliteal (IP) lesions including 33 RCTs with a total of 5745 patients, found that in FP lesions, DCBs and DESs had comparable MAEs. However, in IP lesions, DESs had significantly lower rates of MAEs highlighting the beneficial effect of DES in IP lesions [40].

Our study, to the best of our knowledge, is the most comprehensive meta-analysis addressing the safety and effectiveness of DCB in patients with small CAD as it included 24 studies; also, it had many stratifications and sub-group analyses that previous meta-analyses had missed due to the limited amount of papers included: (1) we stratified the incidence of MACE according to the indication of intervention used, the type of study, either RCT and observational, and the language of the included studies, (2) the statistical power of our meta-analysis is substantially higher, leading to more reliable results, (3) the inclusion of 11 outcomes allowed comprehensive evaluation of the therapeutic efficacy and safety of DCB for small-vessel CAD, (4) we conducted a TSA analysis, so that we can assess if the evidence is conclusive.

There are some limitations to be addressed in our study. Firstly, the included studies in terms of MACE and small vessels definition have high statistical heterogeneity which could lead to some biases in the pooled estimates, however, sensitivity analyses were performed to test the robustness of the results. Secondly, the study was unable to compare the effectiveness of different types of DCB or DES as there was limited data available, so this study could be a hypothesis-generating study on some insights on the difference between DCB and DES. Third, bailout stenting with BMS in the DCB may make it difficult to directly compare the effectiveness of DCB versus DES. Fourth, the sequence of devices (DEB first or BMS first) could have contributed to heterogeneity. Lastly, the criteria for defining small vessels and the length of follow-up varied between the included studies.

Impact on daily practice

Interventional approaches for the management of small CAD, yet, not well established in the clinical practice, here we conducted a systematic review and meta-analysis assessing the efficacy and safety of DCB compared to DES in the setting of small CAD. Our study showed that DCB intervention, when compared to DES setting, showed non-inferiority according to clinical outcomes assessed as MACE, all-cause death, cardiac death, MI, TLR, TVR, and stent thrombosis; however, it showed superiority in angiographic outcomes as MLD and NLG. While there was no significant difference in terms of LLL, after sensitivity analysis, DCB was superior to DES. On the other hand, DCB was associated with higher odds regarding in-segment binary restenosis, and by performing a sensitivity analysis, DCB was not-inferior to DES. So, DCB intervention is a safe and feasible intervention to treat small coronary artery disease in patients undergoing PCI. This study can be a guide of using DCB as a primary intervention in patients with de novo small CAD undergoing PCI regards to its safety profile and feasibility approach.

Conclusion

In conclusion, the present meta-analysis suggested that, in terms of clinical outcomes, DCB is comparable to DES in the therapeutic efficacy and safety of de novo small CAD. However, regarding angiographic outcomes, DCB showed favorable results in terms of MLD, NLG outcomes, and LLL but after a sensitivity analysis model. Hence, DCB should be validated as an alternative treatment of choice for patients presented with small CAD with respect to the characteristics of the patients, and the complexity of the lesions. Large-volume RCTs with long-term follow-up durations are necessary to gain a more comprehensive clue understanding of the safety and efficacy of DCB in the treatment of small vessel CAD.

Data availability

The data underlying this article are available in the article and in its online supplementary material.

Abbreviations

DCB:

Drug-coated balloons

DES:

Drug-eluting stents

CAD:

Coronary artery disease

PCI:

Percutaneous coronary intervention

PRISMA:

Systematic Reviews and Meta-analysis

TSA:

Trial sequential analysis

OR:

Odds ratio

NA:

Not Assigned

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Acknowledgements

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Author information

Authors and Affiliations

  1. Faculty of Medicine, Al-Azhar University, Cairo, Egypt

    Ahmed Abdelaziz, Mohamed Abdelaziz, Mohamed Hatem Ellabban & Abdelrahman Hafez

  2. Medical Research Group of Egypt (MRGE), Cairo, Egypt

    Hanaa Elsayed, Karim Atta, Mohamed Abdelaziz, Mahmoud Ezzat, Manar Alaa Mabrouk, Mohamed Hatem Ellabban, Emad Addin Zawaneh & Abdelrahman Hafez

  3. Faculty of Medicine, Zagazig University, Zagazig, Egypt

    Hanaa Elsayed

  4. Institute of Medicine, National Research Mordovia State University, Saransk, Russia

    Karim Atta

  5. The Brooklyn Hospital Center, Brooklyn, NY, USA

    Muhammad Desouky

  6. Faculty of Medicine Kafrelsheikh University, Kafrelsheikh, Egypt

    Mahmoud Gomaa

  7. Al Muthanna University College of Medicine, Samawah, Iraq

    Hallas Kadhim

  8. Internal Medicine Department, Medicine College, University of Kufa, Najaf, Iraq

    Ahmed Mechi

  9. Faculty of Medicine, Menoufia University, Menoufia, Egypt

    Mahmoud Ezzat

  10. Faculty of Medicine, Fayoum University, Fayoum, Egypt

    Manar Alaa Mabrouk

  11. Faculty of Medicine, Jordan University of Science and Technology, Ar-Ramtha, Jordan

    Emad Addin Zawaneh

  12. Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Mohamed Yasser Elnaggar

  13. Department of Cardiovascular Medicine, Cairo University Hospitals, Cairo, Egypt

    Ahmed O. Sena

  14. Hematology and Oncology Department, Mayo Clinic, Scottsdale, AZ, USA

    Ahmed Bahnasy

  15. University of Texas MD Anderson, Houston, TX, USA

    Emad Singer

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  1. Ahmed Abdelaziz
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Contributions

Ahmed Abdelaziz: Conceptualization, Supervision, data collection revision, statistical analysis, writing – original draft and editing. Hanaa Elsayed: screening, data collection, original draft writing Karim Atta: Full-text screening, data collection, data validation, TSA analysis. Muhammad Desouky: data validation, data revision, Final version, Mahmoud Gomaa: data collection, writing – revision, Manuscript revision. Hallas Kadhim: data collection, quality assessment. Ahmed Mechi: data collection, data validation, Final version, TSA analysis. Mohamed Abdelaziz: screening, data collection, revision of data collection, quality assessment. Mahmoud Ezzat: screening, data collection, data revision for analysis. Manar Alaa Mabrouk: quality assessment, data collection, writing – revision, TSA analysis. Mohamed Hatem Elabban: summary and characteristics, quality assessment, writing – revision. Emad Addin Zawaneh: summary and characteristics, quality assessment, writing – revision. Abdelrahman Hafez: summary and characteristics, quality assessment, writing – revision. Mohamed Yasser Elnaggar: quality assessment, manuscript drafting and writing.Ahmed O. Sena: writing – original draft, data revision, Manuscript revision. Ahmed Bahnasy: summary and characteristics, writing – revision, TSA analysis. Emad Singer: writing – revision, data revision, Manuscript revision, supervision.

Corresponding author

Correspondence to Ahmed Abdelaziz.

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Abdelaziz, A., Elsayed, H., Atta, K. et al. Drug-coated balloons versus drug-eluting stents in patients with small coronary artery disease: an updated meta-analysis. BMC Cardiovasc Disord 25, 339 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-024-04426-5

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Keywords

BMC Cardiovascular Disorders

ISSN: 1471-2261

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