Angioplasty vs Stent: How the Procedures Differ

Angioplasty is the broader procedure: a catheter-tipped balloon is threaded into a narrowed artery and inflated to push the blockage open. A stent is a small mesh tube that can be placed during angioplasty to hold the artery open afterward. In other words, every stent procedure involves angioplasty, but not every angioplasty involves a stent. The distinction matters because each approach has trade-offs in durability, complications, medication requirements, and which arteries respond best. In coronary arteries, stenting has largely replaced balloon-only angioplasty for most situations, but the picture is more nuanced in leg arteries, small vessels, and certain emergency scenarios.

Why Stents Exist in the First Place

When a balloon is inflated inside a narrowed artery, it cracks and compresses the fatty plaque against the vessel wall. The artery opens up. But arteries are elastic, and the moment the balloon deflates, the vessel tries to spring back toward its original shape. This “elastic recoil” was one of the original frustrations of balloon angioplasty. Early research quantified the problem: after balloon-only treatment of coronary arteries, the vessel lost roughly a third of the diameter gain almost immediately due to recoil, compared with only about 3 to 4 percent when a stent was placed to scaffold the artery open.¹ The same phenomenon showed up in the iliac arteries of the pelvis, where elastic recoil was identified as a significant limitation of balloon-only treatment.²

Beyond immediate recoil, balloon-only angioplasty also carried a high rate of restenosis, which is the artery gradually narrowing again over weeks to months as the vessel wall heals and scar tissue grows inward. Stents addressed both problems: they physically prevented the artery from snapping back and reduced (though did not eliminate) the rate of re-narrowing. By the mid-1990s, stenting during coronary angioplasty had become the default rather than the exception.

How the Procedure Differs With and Without a Stent

In a balloon-only angioplasty, the interventional cardiologist inflates the balloon at the blockage, confirms the artery has opened on imaging, and removes the catheter. The procedure is faster, uses less hardware, and leaves nothing behind in the artery. In a stent procedure, a collapsed metal mesh rides on the balloon catheter; when the balloon inflates, the stent expands and locks into the vessel wall. The balloon is then deflated and withdrawn, but the stent stays permanently. Both procedures are performed through the same small puncture in the wrist or groin, and recovery time is similar.

The practical difference for patients mostly comes down to what happens next. After stenting, you need dual antiplatelet therapy, typically aspirin plus a second blood thinner, to prevent clots from forming on the stent’s metal surface before the vessel lining has a chance to grow over it. A meta-analysis of randomized trials found that shorter courses of dual therapy (less than 12 months) reduced major bleeding without significantly increasing clot-related events, while extending therapy beyond 12 months further lowered heart attack and stent clot risk but at the cost of more bleeding.³ After balloon-only angioplasty, medication requirements are usually lighter and shorter.

Bare-Metal Versus Drug-Eluting Stents

Early stents were bare metal, meaning plain steel or cobalt-chromium tubes. They solved the recoil problem but still allowed scar tissue (neointimal hyperplasia) to grow through the mesh gaps, causing the artery to narrow again in roughly 20 to 30 percent of patients within the first year. Drug-eluting stents changed that equation. These stents are coated with a medication, commonly sirolimus or paclitaxel, that slowly leaches into the vessel wall and suppresses the cell growth responsible for re-narrowing.

Early human follow-up of sirolimus-eluting stents showed that the scar tissue buildup inside the stent was virtually absent at both six months and one year, and remained suppressed out to two years.⁴ ⁵ Paclitaxel-coated stents showed a similar dose-dependent reduction in tissue overgrowth in animal models.⁶ Drug-eluting stents are now used in the vast majority of coronary stent procedures worldwide.

That does not mean drug-eluting stents are risk-free. When re-narrowing does occur after a drug-eluting stent, the tissue looks different under a microscope: it tends to have fewer smooth muscle cells and can develop atherosclerotic-like changes within the scar tissue earlier and more frequently than bare-metal stent restenosis.⁷ And lesions that develop clots after drug-eluting stent placement tend to be more severely underexpanded than those that merely re-narrow.⁸ Proper stent sizing and full expansion during implantation remain crucial.

Stenting During a Heart Attack

During an acute heart attack, the goal is to reopen the blocked coronary artery as fast as possible. Both balloon angioplasty and stenting can accomplish this, but stenting produces more durable results. In one randomized trial, recurrent heart attack occurred in about 7 percent of patients treated with balloon angioplasty alone versus 1 percent of those who received a stent. The need for a repeat procedure on the same artery was also dramatically lower after stenting: 4 percent compared with 17 percent.⁹

A larger trial comparing four strategies (balloon angioplasty alone, balloon angioplasty with abciximab, stenting alone, and stenting with abciximab) confirmed the pattern. At six months, the main difference between groups came down entirely to how often patients needed a repeat procedure on the same vessel, which ranged from about 16 percent after balloon-only treatment to about 5 percent after stenting with abciximab. The rate of angiographic restenosis was roughly 41 percent after balloon angioplasty versus 22 percent after stenting.¹⁰ Death and stroke rates, however, were similar across all groups. Stenting’s main advantage in the heart attack setting is keeping the artery open, not an overall survival benefit.

Quality of Life After Each Approach

Given the lower repeat-procedure rates, it is not surprising that stented patients report better quality of life in the first several months. The Stent-PAMI trial found that at six months, patients who received stents during a heart attack had less frequent chest pain, less bodily pain, and improved perception of their disease compared to those treated with balloon angioplasty alone. By 12 months, though, those differences had faded. The researchers attributed the early quality-of-life gap to the much higher need for repeat procedures in the balloon-only group during the first six months.¹¹

Separately, for patients with stable chest pain (not a heart attack), the RITA-2 trial found that angioplasty patients experienced significantly greater improvements in physical functioning, energy, and general health at three months and one year compared with patients treated with medication alone. But at three years, those differences had largely disappeared, partly because more than a quarter of the medication group had eventually undergone a procedure anyway.¹²

Leg Arteries Tell a Different Story

The heart is not the only place these procedures are performed. Peripheral artery disease, most commonly affecting the legs, is treated with both balloon angioplasty and stenting. But the results do not mirror what happens in coronary arteries.

In the thigh’s superficial femoral artery, a technology assessment found that balloon-expandable bare-metal stents offered no significant patency advantage over balloon angioplasty at 6, 12, or 24 months. Self-expanding stents did perform better, with improved vessel openness at all three time points, but even with that advantage, re-intervention rates, complication rates, and amputation rates were similar between groups.¹³ The femoral artery sits in a mechanically hostile environment. It bends, twists, and compresses with every step, and rigid metal stents can fracture or kink in ways that rarely happen in coronary arteries.

Below the knee, the evidence is even more mixed. A Cochrane review of five trials found that stenting had a higher technical success rate than balloon angioplasty alone, but short-term patency, complication rates, amputations, and mortality were not clearly different.¹⁴ The exception was drug-eluting stents: the ACHILLES trial showed that sirolimus-eluting stents reduced restenosis (about 22 percent versus 42 percent) and improved patency compared with balloon angioplasty in below-knee arteries at one year.¹⁵ Network meta-analyses of below-knee disease have also consistently found drug-eluting stents superior to both bare-metal stents and balloon angioplasty for restenosis and repeat revascularization.¹⁶

Drug-Coated Balloons: Angioplasty Fights Back

One of the more interesting recent developments is the drug-coated balloon. This is a regular angioplasty balloon whose surface carries a drug (usually paclitaxel) that transfers to the vessel wall during inflation. The balloon is then removed, leaving no permanent implant behind, but the drug remains in the tissue and suppresses scar formation. It is essentially an attempt to get the restenosis benefit of a drug-eluting stent without the lifelong metal scaffold.

In small coronary arteries (less than about 2.75 mm in diameter), drug-coated balloons have performed well. A literature review concluded that current data supports drug-coated balloon use in small vessels, with similar efficacy and safety to drug-eluting stents.¹⁷ The BASKET-SMALL 2 trial confirmed maintained efficacy and safety of drug-coated balloons versus drug-eluting stents up to three years in small-vessel disease.¹⁸ The PICCOLETO-II trial’s three-year follow-up actually showed a higher risk of major cardiac events in patients treated with current-generation drug-eluting stents compared with a newer paclitaxel drug-coated balloon in small vessels.¹⁹

From a cost perspective, a recent analysis found no meaningful difference in cost-effectiveness between drug-coated-balloon-only angioplasty and drug-eluting stent angioplasty, suggesting that cost should not drive the choice between the two.²⁰ The attraction of the drug-coated balloon approach is less about saving money and more about avoiding a permanent implant, which matters for patients who may need future procedures on the same artery or who are at higher bleeding risk from prolonged dual antiplatelet therapy.

When a Stent Has Already Failed

If a stent re-narrows (in-stent restenosis), the question becomes what to do next. A meta-analysis of four randomized trials involving over 900 patients compared placing a new drug-eluting stent inside the old one versus simply doing balloon angioplasty. Over an average follow-up of nearly four years, drug-eluting stents significantly reduced the need for repeat procedures. However, the rates of death, heart attack, and blood clots in the stent were not different between the two strategies.²¹ This is a recurring theme: stents tend to reduce the need for additional procedures without dramatically changing mortality.

Carotid Arteries and Stroke

When a blockage in the carotid artery (the major neck artery supplying the brain) occurs alongside a stroke, interventionalists must decide whether to place a stent or simply inflate a balloon. A systematic review and meta-analysis of patients with tandem occlusions (a blockage in the carotid plus one further up in the brain) found that acute carotid stenting was associated with roughly double the odds of good functional outcomes at three months and of successful blood-flow restoration compared with balloon angioplasty alone, with no difference in death or brain bleeding.²²

A separate large database study of carotid interventions during acute stroke found that angioplasty alone carried significantly higher in-hospital mortality (about 9 percent versus about 4 percent) and a higher rate of procedure-related stroke compared with stenting.²³ Age plays a role in carotid stenting decisions, though. Data from the SPACE trial showed that the risk of stroke or death within 30 days of carotid stenting rose significantly with age, with a sharp jump above 68 years, while surgical risk did not track with age the same way.²⁴

What Stents Do to the Artery Wall Long-Term

One underappreciated difference between balloon-only angioplasty and stenting is what happens to the artery’s ability to relax and contract on its own. A healthy artery adjusts its diameter in response to blood-flow demands. Stenting disrupts that ability. A study measuring the artery’s response to acetylcholine (a chemical that normally causes arteries to relax) found significantly worse endothelial dysfunction downstream of stented segments compared with segments treated with balloon angioplasty alone. Every stented patient showed some degree of abnormal vessel constriction, while the balloon-only group had a mixed response.²⁵

Follow-up research tracking the time course of recovery found that all forms of intervention, whether balloon, drug-coated balloon, bare-metal stent, or drug-eluting stent, profoundly impaired the endothelium’s ability to relax the vessel immediately after the procedure. Arteries treated with plain balloons and drug-coated balloons showed signs of recovering vasodilatory function by one month, whereas drug-eluting stent segments recovered more slowly.²⁶ This does not necessarily translate into clinical events for most patients, but it does matter for the small subset who develop chest pain from artery spasm rather than new blockages after their procedure.

Imaging Guidance Makes Both Approaches Better

Whether the operator uses a balloon alone or places a stent, how well the procedure is executed matters as much as which tool is chosen. Intravascular ultrasound, a tiny probe inserted into the artery to see the vessel wall from inside, has been shown to improve outcomes for stent placement. A randomized trial of long stent placements found that ultrasound guidance cut the restenosis rate roughly in half (about 23 percent versus 45 percent) and reduced the need for repeat procedures at 12 months compared with standard X-ray guidance alone.²⁷ A meta-analysis of randomized trials confirmed a roughly 27 percent reduction in angiographic restenosis when intravascular ultrasound was used to guide stent placement.²⁸

Bioresorbable Scaffolds: The Dissolving Stent That Stumbled

If the main downside of a stent is that it stays in the artery forever, what about a scaffold that holds the artery open while it heals and then dissolves? This was the premise behind bioresorbable vascular scaffolds, made from materials like polylactic acid that the body gradually absorbs over two to three years. The concept generated enormous excitement.

Reality was disappointing. The largest randomized trial comparing a bioresorbable scaffold (the Absorb device) with a standard metallic drug-eluting stent found similar rates of target-vessel failure at two years, but a nearly fourfold increase in the rate of device clotting with the scaffold.²⁹ A meta-analysis of all randomized trials reinforced this finding: bioresorbable scaffolds carried a higher risk of target-lesion failure, driven by more heart attacks related to the treated vessel, and roughly triple the risk of clotting compared with everolimus-eluting metallic stents. The excess risk emerged primarily between one and two years after implantation.³⁰ A separate systematic review confirmed higher rates of both target-lesion failure and in-scaffold narrowing in the bioresorbable group.³¹ The Absorb scaffold was eventually pulled from the market. Newer designs with thinner struts and different materials are being tested, but for now, the dissolving stent remains a concept waiting for better engineering.

Stent Fractures

Because stents are permanent metal structures sitting inside a living, moving artery, they can break. Stent strut fractures are more common in arteries that experience a lot of mechanical stress (the legs especially, but coronary arteries too) and in vessels with heavy calcium deposits or branches. An analysis of fracture patterns found that calcified and bifurcation lesions were strongly associated with fracture in drug-eluting stents, and that fractures carried dramatically increased odds of stent failure.³² Balloon-only angioplasty, by contrast, leaves nothing behind that can break. This is one reason operators sometimes prefer a balloon-only or drug-coated-balloon strategy in anatomically challenging locations where a rigid metal scaffold might not hold up.

Older Adults and the Stent-Versus-Bare-Metal Question

For patients aged 75 and older, the choice between drug-eluting and bare-metal stents is sometimes debated because of concerns about prolonged blood-thinner use. A study comparing the two in this age group found that drug-eluting stent patients required longer dual antiplatelet therapy (about 12 months versus about 4 months on average) but had substantially lower rates of heart attack (roughly 9 percent versus 17 percent) and repeat revascularization (about 8 percent versus 22 percent) without any increase in bleeding events.³³ The idea that older patients should automatically get bare-metal stents to avoid blood thinners has largely fallen out of favor.

The “No-Reflow” Problem

Both balloon angioplasty and stenting share one frustrating complication: no-reflow. This is when the artery appears wide open on imaging after the procedure, but blood flow at the tissue level does not return. The underlying causes include tiny debris from the plaque breaking off and clogging downstream capillaries, swelling of the capillary walls themselves, and inflammatory cell buildup in the smallest vessels.³⁴ If no-reflow appears within the first 45 minutes after reperfusion, it tends to be driven by tiny clot fragments, which can sometimes be treated. When it persists longer, it usually reflects irreversible tissue death, making it much harder to manage regardless of whether a stent was placed.³⁵ No-reflow is one of those complications that reminds us the real bottleneck in heart-attack treatment is often not the main artery but the microscopic blood vessels beyond it.