Optimal antiplatelet strategies after complex percutaneous coronary intervention in newer drug-eluting stent era: a bayesian network meta-analysis of randomized-controlled trials

Background Patients underwent complex percutaneous coronary intervention (PCI) are at higher ischemic and bleeding risk. Extended dual-antiplatelet therapy (DAPT) is usually recommended in this population to prevent future ischemic events in exchange with risk of bleeding. Purpose We aimed to investigate efficacy and safety of short-term DAPT after complex PCI. Method A literature search was conducted in PubMed, Embase, and the Cochrane Library up until January 2026. Randomized controlled trials (RCTs) were included if they compared at least two different antiplatelet strategies following complex PCI using 2nd generation or newer drug-eluting stents. Complex PCI was defined as the treatment of three vessels or ≥3 lesions, implantation of ≥3 stents, bifurcation treatment with a two-stent technique, total stent length ≥60 mm, or intervention for a chronic total occlusion as the target lesion. The primary outcomes were cardiovascular mortality, stroke, and any myocardial infarction. The secondary endpoint was major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. Results A total of 10 RCTs comprising 21,790 patients were included (female 20.9%; mean age 66.2±11.4 years). Compared with standard 12-month DAPT, 3–6 months of DAPT followed by SAPT ranked highest for reducing cardiovascular mortality (HR 0.67, 95% CrI 0.56–0.78; SUCRA=0.73), myocardial infarction (HR 0.57, 95% CrI 0.50–0.63; SUCRA=0.86), and stroke (HR 0.58, 95% CrI 0.49–0.68; SUCRA=0.91), followed by 12 months of P2Y12 inhibitor monotherapy, 3 months of DAPT followed by 9 months of P2Y12 inhibitor monotherapy, and aspirin monotherapy. For major bleeding, 1 month of DAPT followed by 23 months of P2Y12 inhibitor monotherapy ranked best (HR 0.77, 95% CrI 0.67–0.89; SUCRA=0.77), followed by 3–6 months of DAPT followed by SAPT (HR 0.86, 95% CrI 0.72–1.04; SUCRA=0.38), whereas 1 month of DAPT followed by SAPT ranked last (SUCRA=0.29). Conclusions Patients underwent complex PCI with newer generation of drug-eluting stents, 3-to-6 months DAPT followed by SAPT and P2Y12i monotherapy after index procedures lowered risk of CV mortality, MI, stroke and major bleeding compared to standard 12 months of DAPT.