Stent therapy (versus balloon angioplasty alone) provides predictable outcomes following percutaneous coronary intervention (PCI), in both the immediate, periprocedural setting and in durable (6-12 month) follow-up, in patients with target vessel reference diameters greater than or equal to 3.0 mm. The rate of positive outcomes for stenting, versus balloon angioplasty, is less robust for smaller (< 3.0 mm) coronary vessels. Specific attributes of stent design, including strut thickness and metal alloy composition, influence stent performance characteristics, particularly in smaller coronary vessels. Polymer-based drug elution from stents may reduce or eliminate the inflammatory-neointimal proliferative response provoked by stent deployment but the drug delivery platform remains critically important. The best drug-eluting stent (DES) platform for small coronary vessel applications is one incorporating low profile, enhanced flexibility, and ease of deployment (balloon expandability), as well as providing adequate endoluminal surface coverage for scaffolding and uniform drug delivery. DES specifically designed for small-vessel application will become the standard for small vessel PCI.