Comment on “A Projected Cost Analysis of Plain Balloon Versus Drug Coated Balloon Angioplasty for the Treatment of Femoropopliteal Segment Disease”

We read with great interest the article by Lisik et al. [1], which provides a timely and valuable cost projection analysis comparing POBA and DCB for femoropopliteal disease. The study's strength lies in its application of real-world hospital costing data to modeled reintervention rates derived from RCTs, offering a pragmatic Australian perspective. However, we wish to raise several methodological and interpretative points for further discussion. Firstly, the model assumes that all reinterventions employ the same technology as the index procedure (POBA or DCB). This may not reflect real-world practice, where treatment escalation is common following early failure. For instance, a POBA failure within 12 months would likely be treated with a stent or a DCB, substantially increasing the cost beyond the model's estimate. A more nuanced sensitivity analysis incorporating plausible treatment escalation pathways would strengthen the conclusions. Secondly, while the authors correctly identify the claudicant bias in the underlying RCT data, the discussion could be extended to the cost implications for the Chronic Limb-Threatening Ischaemia (CLTI) cohort. CLTI patients have higher mortality, amputation rates, and resource utilization. The recently published BASIL-3 trial found no significant clinical benefit for DCB over POBA in the femoropopliteal segment for CLTI patients [2]. This pivotal finding suggests that the favorable cost profile of DCB projected by Lisik et al. may not be generalizable to the CLTI population, a critical subgroup with the highest healthcare burden. The cost model could be stratified by clinical presentation (claudication vs. CLTI) using subgroup data where available. Finally, the analysis focuses on direct procedural and admission costs. In publicly funded systems, opportunity costs related to angiography suite time and repeated hospital admissions are significant. A cost-consequence analysis incorporating metrics like amputation-free survival and quality-adjusted life years (QALYs), as utilized in the BASIL trial health economic analysis, would provide a more holistic view of value [3]. Future research should aim for patient-level, prospective cost-effectiveness analyses aligned with contemporary RCTs like BASIL-3 to definitively guide resource allocation for both claudicant and CLTI populations. All the authors contributed to the study conception and design. The first draft of the manuscript was written by Bingning Ma, and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.