Objective To compare the efficacy and safety of biodegradable polymer drug eluting stents with those of bare metal stents and durable polymer drug eluting stents.Design Mixed treatment comparison meta-analysis of 258 544 patient years of follow-up from randomized trials.Data sources and study selection PubMed, Embase, and Central were searched for randomized trials comparing any of the Food and Drug Administration approved durable polymer drug eluting stents (sirolimus eluting, paclitaxel eluting, cobalt chromium everolimus eluting, platinum chromium everolimus eluting, zotarolimus eluting-Endeavor, and zotarolimus eluting-Resolute) or biodegradable polymer drug eluting stents, with each other or against bare metal stents.Outcomes Long term efficacy (target vessel revascularization, target lesion revascularization) and safety (death, myocardial infarction, stent thrombosis). Landmark analysis at more than one year was evaluated to assess the potential late benefit of biodegradable polymer drug eluting stents.Results From 126 randomized trials and 258 544 patient years of follow-up, for long term efficacy (target vessel revascularization), biodegradable polymer drug eluting stents were superior to paclitaxel eluting stents (rate ratio 0.66, 95% credibility interval 0.57 to 0.78) and zotarolimus eluting stent-Endeavor (0.69, 0.56 to 0.84) but not to newer generation durable polymer drug eluting stents (for example: 1.03, 0.89 to 1.21 versus cobalt chromium everolimus eluting stents). Similarly, biodegradable polymer drug eluting stents were superior to paclitaxel eluting stents (rate ratio 0.61, 0.37 to 0.89) but inferior to cobalt chromium everolimus eluting stents (2.04, 1.27 to 3.35) for long term safety (definite stent thrombosis). In the landmark analysis after one year, biodegradable polymer drug eluting stents were superior to sirolimus eluting stents for definite stent thrombosis (rate ratio 0.29, 0.10 to 0.82) but were associated with increased mortality compared with cobalt chromium everolimus eluting stents (1.52, 1.02 to 2.22). Overall, among all stent types, the newer generation durable polymer drug eluting stents (zotarolimus eluting stent-Resolute, cobalt chromium everolimus eluting stents, and platinum chromium everolimus eluting stents) were the most efficacious (lowest target vessel revascularization rate) stents, and cobalt chromium everolimus eluting stents were the safest with significant reductions in definite stent thrombosis (rate ratio 0.35, 0.21 to 0.53), myocardial infarction (0.65, 0.55 to 0.75), and death (0.72, 0.58 to 0.90) compared with bare metal stents.Conclusions Biodegradable polymer drug eluting stents are superior to first generation durable polymer drug eluting stents but not to newer generation durable polymer stents in reducing target vessel revascularization. Newer generation durable polymer stents, and especially cobalt chromium everolimus eluting stents, have the best combination of efficacy and safety. The utility of biodegradable polymer stents in the context o...

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-Contemporary second-generation drug-eluting stents (DES) have superior efficacy and safety compared with early generation stents in patients undergoing percutaneous coronary intervention (PCI), in part related to their thinner struts. Whether newer generation ultra-thin DES further improve clinical outcomes compared with older second-generation thicker strut DES is unknown. -We searched PUBMED, EMBASE, and CENTRAL for randomized clinical trials that compared newer generation ultra-thin strut DES (defined as strut thickness<70 microns) versus thicker strut second-generation DES and reported clinical outcomes. The primary outcome was target lesion failure (TLF) (composite of cardiovascular death, target vessel myocardial infarction (MI) or ischemia-driven target lesion revascularization (TLR)) evaluated at 1-year follow-up. Tests for subgroup effects based on the ultra-thin strut DES type and based on the comparator DES type were performed using meta-regression analysis. -We identified 10 trials that randomized 11,658 patients and evaluated 3 newer generation ultra-thin strut DES: Orsiro stent (60 μm), MiStent (64 μm) and BioMime (65 μm). When compared with thicker strut second-generation DES, newer generation ultra-thin strut DES were associated with a 16% reduction in TLF (RR=0.84; 95% CI 0.72-0.99) driven by less MI (RR=0.80; 95% CI 0.65-0.99). Ultra-thin strut DES were also associated with qualitatively lower rates of any stent thrombosis (RR=0.72; 95% CI 0.51-1.01). Tests for subgroup effects based on the ultra-thin strut DES type (P=0.58) and the comparator DES type (P=0.98) were not significant, suggesting consistent outcomes across the three ultra-thin strut DES and with the different DES comparators. -In patients undergoing PCI, newer generation ultra-thin strut DES further improve 1-year clinical outcomes compared with contemporary thicker strut second-generation DES.