Objective The clinical efficacy of paclitaxel drug-coated balloon in senile coronary small vessel disease was analyzed to provide a clinical reference. Methods The clinical data of 88 senile coronary small vessel disease patients undergoing percutaneous coronary intervention (PCI) admitted to Beijing Renhe Hospital from January 2021 to January 2022 were retrospectively analyzed. Patients were divided into the drug-coated balloon (DCB) group (49 cases, treated with paclitaxel drug-coated balloon) and the drug-eluting stent (DES) group (39 cases, treated with rapamycin stent) according to the different interventional procedures. The treatment effects, angiographic results, occurrences of major adverse cardiac events (MACE) and bleeding were compared between the two groups. Results The overall efficacy of the DCB group was better than the DES group, and the total effective rate was higher than the DES group (P<0.05). Immediately after surgery, the minimum vessel diameter of two groups were larger than preoperative, the degree of vascular stenosis were smaller than preoperative, and the minimum vessel diameter of the DCB group was larger than the DES group, and the degree of vascular stenosis was smaller than the DES group (P<0.05).8 months after surgery, the late lumen loss（LLL） level of the DCB group was lower than the DES group (P<0.05).12 months after surgery, there was no significant difference in the total occurrences of MACE between the two groups (P>0.05).12 months after surgery, the total occurrence of bleeding in the DCB group was lower than the DES group (P<0.05). Conclusion Paclitaxel drug-coated balloon in PCI in senile coronary small vessel disease can effectively prevent secondary stenosis and ensure the efficacy and safety of treatment.