Authors' objectives: To determine which primary endovascular revascularisation strategy represents the most clinical and cost-effective treatment for patients with chronic limb threatening ischaemia who require an endovascular femoro-popliteal, with or without an infra-popliteal revascularisation.

Authors' results and conclusions: Between 29 January 2016 and 31 August 2021, 481 participants [167 (35%) women] of mean age 71.8 years (standard deviation 10.8) were randomised. Major amputation or death occurred in 106 of 160 (66%) participants in the plain balloon angioplasty ± bare metal stenting group, 97 of 161 (60%) participants in the drug-coated balloon angioplasty ± bare metal stenting, and 93 of 159 (58%) participants in the drug-eluting stenting group [adjusted hazard ratios: plain balloon angioplasty ± bare metal stenting vs. drug-coated balloon angioplasty ± bare metal stenting: 0.84 (97.5% confidence interval 0.61 to 1.16), p = 0.22; plain balloon angioplasty ± bare metal stenting vs. drug-eluting stenting: 0.83 (97.5% confidence interval 0.60 to 1.15), p = 0.20]. There were no differences in serious adverse events between the groups. There were no differences in mortality when drug technology arms were pooled versus plain balloon angioplasty ± bare metal stenting. When compared to plain balloon angioplasty, drug-eluting stenting was less costly [−£724 (95% confidence interval −£4975 to £2631)] and resulted in additional 0.048 quality-adjusted life-years (95% confidence interval −0.060 to 0.148). Drug-coated balloon angioplasty was unlikely to be a cost-effective option (probability 52% of being cost-effective at £20,000 per quality-adjusted life-year) while drug-eluting stenting was potentially cost-effective (probability 76% of being cost-effective at £20,000 per quality-adjusted life-year). Neither drug-coated balloon angioplasty ± bare metal stenting, nor drug-eluting stenting, conferred significant clinical benefit over plain balloon angioplasty ± bare metal stenting when used in the femoro-popliteal segment in patients undergoing femoro-popliteal ± infra-popliteal endovascular revascularisation for chronic limb threatening ischaemia. Drug-eluting stenting and drug-coated balloon angioplasty in chronic limb threatening ischaemia patients were found to offer moderate benefits in health economic outcomes particularly when drug-eluting stenting was compared to plain balloon angioplasty.

Authors' methods: Three-arm open-label pragmatic multicentre randomised phase 3 superiority trial. Thirty-five UK NHS vascular units. Patients with chronic limb threatening ischaemia who required an endovascular femoro-popliteal with or without an infra-popliteal revascularisation. Participants were randomly assigned (1 : 1 : 1) to either a femoro-popliteal plain balloon angioplasty with or without bare metal stenting (considered as control or reference), or a drug-coated balloon angioplasty with or without bare metal stenting, or a drug-eluting stenting first revascularisation strategy. The primary outcome was amputation-free survival defined as time to first major amputation or death from any cause. Secondary outcomes included overall survival, limb salvage, major adverse limb events, major adverse cardiac events and other pre-specified clinical and patient reported outcome measures. Serious adverse events were collected up to 30 days following the first revascularisation procedure.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hta/13/81/02

Year Published: 2026

URL for published report: https://www.journalslibrary.nihr.ac.uk/hta/GJAB0915

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GJAB0915

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk