Drug-coated balloons and stents were not associated with reduced risk of amputation or improved quality of life compared with uncoated devices in the SWEDEPAD 1 and 2 trials. In addition, higher five-year mortality with drug-coated devices in patients with intermittent claudication was noted, leading researchers to stress that the safety of paclitaxel-coated devices is an “ongoing discussion”. These late-breaking findings were presented today at the European Society of Cardiology (ESC) 2025 congress (29 August–1 September, Madrid, Spain) and simultaneously published in The Lancet.
SWEDEPAD 1 and 2 were pragmatic, participant-blinded, registry-based randomised trials that set out to determine the clinical impact of drug-coated technology on patients with peripheral arterial disease (PAD).
Explaining the rationale for the trials, co-principal investigator Joakim Nordanstig (University of Gothenburg, Gothenburg, Sweden), said: “Drug-coated balloons and stents have been shown to reduce restenosis and the need for reinterventions in the endovascular treatment of PAD. However, there are uncertainties regarding whether drug-coated devices improve outcomes that are meaningful to patients, quality of life and reducing amputations, and there are some concerns over safety. We investigated these and other endpoints in two trials in PAD—one in chronic limb-threatening ischaemia [CLTI] and one in intermittent claudication—comparing drug-coated and uncoated devices.”
In SWEDEPAD 1, 2,355 patients with CLTI (Rutherford stage 4–6) undergoing infrainguinal endovascular treatment were randomised 1:1 to drug-coated or uncoated balloons or stents. In nearly all of the drug-coated devices implanted, the drug delivered was paclitaxel (>99%). There was no significant difference in the primary endpoint of time to ipsilateral above-ankle amputation with drug-coated versus uncoated devices (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.87–1.27) over five years of follow-up. Target vessel reinterventions were reduced in the drug-coated group during the first year (HR 0.81; 95% CI 0.66–0.98), but this difference disappeared with longer follow-up. There was no difference in all-cause mortality or in quality of life (as assessed using the VascuQoL-6 questionnaire).
In SWEDEPAD 2, 1,155 patients with intermittent claudication (Rutherford stage 1–3) undergoing infrainguinal endovascular treatment were randomised 1:1 after successful guidewire crossing to receive either drug-coated or uncoated balloons or stents. All drug-coated devices implanted delivered paclitaxel. There was no difference in the primary efficacy endpoint of quality of life between the drug-coated and uncoated groups at 12 months (mean difference in VascuQoL-6 scores: –0.02; 95% CI –0.66–0.62). Target vessel reintervention rates were not different at one year or over a median follow-up of 6.2 years. All-cause mortality did not differ over 7.1 years (HR 1.18; 95% CI 0.94–1.48), although higher five-year mortality was noted with drug-coated versus uncoated devices (HR 1.47; 95% CI 1.09–1.98).
Summarising the findings, co-principal investigator Mårten Falkenberg (Sahlgrenska University Hospital and the University of Gothenburg, Gothenburg, Sweden), said: “Paclitaxel-coated devices were not effective in preventing amputation in chronic limb-threatening ischaemia or improving quality of life in intermittent claudication. Given the signal of increased mortality with intermittent claudication, clinicians should carefully evaluate the potential risks and benefits when considering these expensive devices. Devices incorporating antiproliferative agents other than paclitaxel warrant further investigation in PAD.”
Paclitaxel mortality issue “an ongoing discussion”
In a press conference at ESC, Nordanstig commented on how the newly presented SWEDEPAD data compare to other trials in the PAD space. He noted that the results are “a bit different” to those of previously conducted pivotal trials and meta-analyses on drug-coated technology in patients with PAD, which “consistently demonstrated” reduced reintervention rates. “The big difference here I think,” Nordanstig said, “is this is a strategy trial rather than a single device trial, and [the SWEDEPAD findings] might be what is happening when broadly introducing these therapies in a more everyday patient population.”
Nordanstig also touched on the finding in SWEDEPAD 2 that higher five-year mortality was noted with drug-coated versus uncoated devices, stressing that the safety of paclitaxel-coated devices is “still an ongoing discussion” following the identification in 2018 by Katsanos et al of a late mortality signal. He remarked: “It’s hard for us to ignore the fact that it seems that we mirrored that signal in SWEDEPAD 2, but not in SWEDEPAD 1.”
Closing the press conference, session chair Dan Atar (Oslo University Hospital Ulleval, Oslo, Norway) commended the researchers for their use of “hard” endpoints in the SWEDEPAD trials. “That’s a very interesting approach to showing outcomes,” he said.
