IVUS-guided PVI reduces amputation, TLR, restenosis, and all-cause mortality in peripheral arterial diseaseUltrasound guidance may lower amputation risk for peripheral artery disease

This meta-analysis evaluated the clinical outcomes of patients undergoing peripheral vascular interventions (PVI) for peripheral arterial disease (PAD). The study included a large population of 1,110,593 patients to compare the efficacy of intravascular ultrasound (IVUS)-guided PVI against standard angiography-guided PVI. The analysis aimed to determine if the addition of IVUS imaging during the intervention procedure influenced long-term clinical outcomes and procedural success.

The primary focus was on comparing the rates of major complications and reintervention requirements between the two groups. In the study, technical success was found to be similar between the IVUS-guided group and the angiography-guided group (RR=1.01; 95% CI 1.00-1.01). This suggests that while both methods achieve comparable immediate procedural goals, the long-term clinical trajectories for patients may differ based on the guidance technology used during the intervention.

Regarding secondary outcomes, IVUS-guided PVI was associated with a significant reduction in amputation rates (RR=0.75; 95% CI 0.61-0.93). Additionally, all-cause mortality was lower in the group receiving IVUS guidance (RR=0.86; 95% CI 0.79-0.93). The study also reported a significant reduction in target lesion revascularisation (TLR) for those guided by IVUS (RR=0.66; 95% CI 0.48-0.91). Furthermore, the rate of restenosis or occlusion was lower with IVUS guidance (RR=0.74; 95% CI 0.60-0.90).

In terms of major adverse limb events (MALE), the study reported a numerically lower rate in the IVUS group (RR=0.66). However, this specific finding did not reach statistical significance (95% CI 0.40-1.10). No specific data regarding safety, serious adverse events, or tolerability were reported for either intervention group. The results suggest that while several key clinical endpoints showed significant improvements with IVUS, the impact on MALE was observed but not statistically confirmed in this analysis.

These findings contribute to the understanding of imaging modalities in PAD management. While previous literature has established various prognostic markers and comorbidities in PAD patients, these results specifically address the role of intraoperative guidance. The data suggest that IVUS may provide a measurable benefit in reducing long-term complications like amputation and mortality compared to angiography alone.

Several limitations must be considered when interpreting these results. The evidence is predominantly observational, which limits the ability to establish a direct causal link between IVUS use and improved outcomes. Furthermore, the certainty of these findings is rated as low-to-moderate. Because the data are derived from a large meta-analysis of observational studies, inherent biases in reporting and selection may influence the results.

Clinically, these findings suggest that IVUS-guided PVI may be a superior approach for reducing major complications such as amputation and restenosis in patients with peripheral arterial disease. However, because the evidence is not from randomized controlled trials, clinicians should interpret these associations with caution. The similarity in technical success suggests that the primary benefit of IVUS lies in long-term clinical outcomes rather than immediate procedural achievement. Several questions remain for future research. Specifically, more randomized controlled trials are needed to confirm the potential benefits of IVUS and to establish a definitive causal relationship between the technology and improved patient outcomes. Further investigation into the specific mechanisms by which IVUS reduces restenosis rates compared to angiography alone is also warranted.