Drug-Coated Balloon, Drug-Eluting Stent, versus Bare-Metal Stent for Vertebral Artery Ostial Stenosis: A Systematic Review and Network Meta-Analysis

Abstract

Abstract Background Stenosis at the origin of the vertebral artery (VAOS) accounts for approximately one in five posterior circulation ischemic events. Bare-metal stents (BMS) have been the conventional endovascular treatment, but restenosis occurs in 11–67% of cases. Drug-coated balloons (DCB) and drug-eluting stents (DES) are alternative strategies; however, no network meta-analysis has compared all three modalities specifically at the vertebral origin. Methods Five databases—PubMed, Embase, Cochrane CENTRAL, CNKI, and Wanfang—were searched from 2010 through May 2026 for studies comparing at least two of DCB, DES, or BMS in adults with symptomatic VAOS. The search identified 499 records; 393 underwent title and abstract screening after deduplication, from which 60 full-text articles were assessed. A frequentist random-effects network meta-analysis was conducted using the netmeta package (R 4.5.2), with Bayesian sensitivity analysis. The primary endpoint was imaging-confirmed restenosis (≥50%). The protocol was registered with PROSPERO (CRD420261413981). Results Seven studies (three randomized trials and four observational cohorts, N=970; range 46–217) met the inclusion criteria. Compared with BMS, both DES (OR 0.27, 95% CI 0.17–0.45) and DCB (OR 0.39, 95% CI 0.18– 0.83) reduced restenosis. DES and DCB did not differ significantly from each other (OR 1.42, 95% CI 0.58–3.50). Between-study heterogeneity was modest (I²=20.5%). Although the point estimate suggests modest heterogeneity, the wide confidence interval and the small number of studies limit precision. Low I2 in a small network should not be equated with clinical homogeneity. P-scores ranked DES first (88.9%), DCB second (60.7%), and BMS last (0.4%). For perioperative safety, DCB ranked highest (P-score 90.0%). Conclusion Both DES and DCB reduce restenosis compared with BMS in VAOS. Both DES and DCB are associated with lower restenosis rates than BMS. The relative anti-restenosis efficacy of DES versus DCB remains uncertain due to the absence of direct head-to-head comparisons. Treatment selection should be individualized based on lesion characteristics and procedural considerations. The DCB evidence base remains small, and head-to-head comparisons of DES versus DCB at the vertebral origin are needed.