**Abstract**

The cardiovascular complication related to lower limb revascularization is the common cause of mortality in patients with peripheral arterial disease (PAD). The coexisting multisite atherosclerotic vascular disease is increasing risk of major adverse cardiovascular events (MACE). The minimally invasive approach for revascularization, namely, endovascular-first strategy for decreasing risk of intervention is the modern approach. The novel technology of the drug delivering device by paclitaxel, sirolimus, and other antiproliferative drug coated balloon (DCB) and drug eluting stent (DES) to increase the patency of the target artery are trending to use in patients with CLTI. However, the long-term result and safety of a drug delivering device are still controversial. The paclitaxel related to MACE and major adverse limb events (MALE) need to be investigated. The new drug coating balloon, sirolimus demonstrated the excellent short-term result. However, there are some limitations of previous randomized studies and meta-analyses to conclude the best strategy and device to perform the best result for revascularization without increasing risk of MACE and MALE in CLTI patients who candidate for revascularization. This article is summarized the pathophysiology of MACE and MALE in the patients with PAD during revascularization, paclitaxel related cardiovascular complications and sirolimus coated balloon.

**Keywords:** major adverse cardiovascular events, MACE, peripheral arterial disease, PAD, chronic limb-threatening ischemia, CLTI, drug delivering technology, drug coated balloon, DCB, drug eluting stent, DES, paclitaxel, sirolimus coated balloon
