The Mid-Term Effect of Intravascular Ultrasound on Endovascular Interventions for Lower Extremity Peripheral Arterial Disease: A Systematic Review and Meta-Analysis.

Objective: Intravascular ultrasound (IVUS) is an important adjunctive tool for patients with lower extremity peripheral arterial disease (PAD) undergoing endovascular therapy (EVT). The evidence regarding the advantages of IVUS use is evolving, and recent studies have reported con fl icting results. We aimed to perform a meta -analysis to evaluate the effi cacy of IVUS during angiography-guided EVT for patients with PAD. Methods: MEDLINE and EMBASE were searched through April 2023 to identify studies that investigated the outcomes of IVUS with angiography-guided EVT vs angiography-alone-guided EVT. The primary outcome was restenosis/occlusion rate; secondary outcomes were target lesion revascularization, major amputation, and mortality. Results: One randomized controlled trial and 14 observational studies, largely of moderate quality, were included, yielding a total of 708,808 patients with 709,189 lesions that were treated with IVUS-guided EVT (n = 101,405) vs angiography-alone (n = 607,784). Compared with angiography alone, IVUS-guided EVT was associated with a nonsigni fi cant trend towards decreased restenosis/occlusion (relative risk [RR], 0.74; 95% con fi dence interval [CI], 0.54-1.00; I 2 = 60%). Although the risk of target lesion revascularization and mortality were comparable (RR, 0.85; 95% CI, 0.65-1.10; I 2 = 70%; RR, 1.01; 95% CI, 0.79-1.28; I 2 = 43%, respectively), the use of IVUS was also associated with signi fi cantly lower risk of major amputation (RR, 0.74; 95% CI, 0.67-0.82; I 2 = 47%). Subgroup analysis focusing on femoropopliteal disease demonstrated signi fi cantly higher patency (RR, 0.72; 95% CI, 0.52-0.98; I 2 = 73%). However, superiority with major amputation was not observed. Conclusions: IVUS-guided EVT for PAD may possibly be associated with a lower major amputation rate compared with angiography alone -guided EVT, although the difference in patency remained an insigni fi cant trend in favor of IVUSguided EVT. Adjunctive use of IVUS during EVT may be bene fi cial, and further prospective studies are warranted to delineate this relationship and the applicability of this technology in routine practice.