Small vessel coronary artery disease (SVD) remains one of the most challenging subsets of coronary artery disease encountered in interventional cardiology. Percutaneous coronary intervention (PCI) in small coronary vessels is associated with higher rates of restenosis, target lesion revascularization, and adverse cardiovascular outcomes. Drug-eluting stents (DES) have significantly improved outcomes compared to bare-metal stents; however, limitations such as permanent metallic implantation, chronic inflammation, and late stent thrombosis remain concerns. Drug-coated balloons (DCB) have emerged as an alternative revascularization strategy that delivers antiproliferative drugs without leaving a permanent implant. This study reviews the comparative effectiveness of DES and DCB in treating small vessel coronary disease, evaluating procedural success, restenosis rates, major adverse cardiovascular events (MACE), late lumen loss, and long-term clinical outcomes. A conceptual Integrated Small Vessel Revascularization Framework (ISVRF) is proposed to guide clinical decision-making. Current evidence suggests that DCB therapy may offer comparable efficacy to modern DES while reducing implant-related complications in selected patient populations.