Purpose: Drug-coated balloons (DCBs) are widely used in the endovascular management of peripheral arterial disease (PAD), with evidence demonstrating improved vessel patency and reduced target lesion revascularisation (TLR). However, concerns regarding long-term safety of paclitaxel-coated devices and recent findings from the SWEDEPAD trials have reignited debate regarding their role in contemporary practice. This review evaluates the ongoing clinical justification for DCB use in PAD. Methodology: A structured review of randomised controlled trials (RCTs), contemporary meta-analyses, international guideline recommendations, and recently published SWEDEPAD trial was performed to assess the efficacy, safety, and clinical utility of DCBs in PAD. Results: Early RCTs (THUNDER, FemPac, LEVANT-2) demonstrated improved patency and reduced TLR compared to plain balloon angioplasty, supporting widespread adoption in femoropopliteal disease. Subsequent guidelines recommended DCB use as standard practice. However, the 2018 Katsanos meta-analysis raised concerns regarding increased late mortality associated with paclitaxel-coated devices, leading to regulatory scrutiny. The recent SWEDEPAD trial demonstrated that patients with chronic limb-threatening ischaemia, paclitaxel-coated devices were not associated with reductions in major amputation or all-cause mortality compared with uncoated devices. In patients with intermittent claudication, DCB failed to improve disease-specific quality of life and was associated with a higher five-year mortality incidence. Conclusion: DCBs remain effective in reducing restenosis and repeat intervention in PAD. However, emerging evidence challenges assumptions regarding their routine use, particularly in intermittent claudication. Current evidence supports a more selective, patient-centred approach rather than universal application. Ongoing uncertainty regarding long-term safety and outcomes of DCBs underscores the need for further high-quality evidence.