8.1 Ultrasound Imaging for Endovascular Interventions: A New Standard?

These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.

Faculty Disclosures     Vendor Acknowledgments

2024 IAGS Summary Document

Statement of the problem or issue

Endovascular interventions have been performed for more than 60 years and intravascular ultrasound (IVUS) for more than 40 years, and yet for some reason IVUS is infrequently used for procedural support here. Advantages of IVUS over standalone angiography during endovascular interventions are presented in Table 1.

Table 1. Advantages of IVUS in endovascular interventions.

Ca++ = calcium/calcification; MLA = minimal lumen area.

There are robust data that IVUS improves clinical outcomes in percutaneous coronary interventions (PCI). What about in endovascular interventions? In a comprehensive meta-analysis of 16 randomized trials with 7814 patients, with weighted mean follow-up of more than 2 years (28.8 months), incorporation of IVUS led to lower risk of major adverse cardiac events (MACE, RR=0.67, P<.001), including cardiac death (RR=0.49, P<.001), stent thrombosis (RR=0.63, P=.046), and target-lesion revascularization (TLR, RR=0.67, P=.01).¹ But is the same true for endovascular interventions? There are much fewer supportive data in the endovascular area, but evidence is accumulating. In a randomized trial of 150 patients undergoing femoropopliteal intervention there was a very significant reduction in the primary endpoint, binary restenosis at 12 months, favoring IVUS over angiography alone (Figure 1).²

Figure 1. Restenosis after femoropoliteal intervention. From: JACC Cardiovasc Interv. 2022;15(5):536-546.

There are also non-randomized, propensity-matched, observational data. In a large study of over a half million patients from 2016 to 2019, there were fewer adverse limb events, lower incidence of acute limb ischemia, and fewer major amputations when IVUS was employed during peripheral vascular interventions rather than angiography alone (Figure 2).³

Figure 2. Adverse events with peripheral vascular interventions. ALI = acute limb ischemia; MALE = major adverse limb events; NNT = number needed to treat. From: JACC Cardiovasc Interv. 2022;15(20)­:2080-2090.

Gaps in current knowledge

Despite the above data, the overall use of IVUS to support peripheral endovascular interventions in clinical practice is low. In the study cited above, the rates of IVUS use varied by operator specialty, with interventional radiologists having the highest use, followed by cardiologists, surgeons and other specialists (Figure 3).³ Further, while the rate of IVUS use in peripheral endovascular interventions increased over time, on average it was used in fewer than 1 in 8 cases.

Figure 3. Use of IVUS in peripheral vascular interventions, quarterly data, 2016-2019. From: JACC Cardiovasc Interv. 2022;15(20)­:2080-2090.

Possible solutions and future directions

Barriers to greater IVUS use and potential solutions to overcome these are shown in Table 2.

Table 2.  Reasons for low IVUS use and possible steps to close the gap.

Understanding which of these barriers are predominant at your own hospitals will help operators devise site-specific approaches to overcoming these roadblocks.

References

1. Sreenivasan J, Reddy RK, Jamil Y, et al. Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention: A systematic review and meta-analysis of randomized trials. J Am Heart Assoc. 2024;13(2):e031111. doi: 10.1161/JAHA.123.031111. PMID: 38214263.
2. Allan RB, Puckridge PJ, Spark JI, Delaney CL. The impact of intravascular ultrasound on femoropopliteal artery endovascular interventions: A randomized controlled trial. JACC Cardiovasc Interv. 2022;15(5):536-546. doi: 10.1016/j.jcin.2022.01.001. PMID: 35272779.
3. Divakaran S, Parikh SA, Hawkins BM, et al. Temporal trends, practice variation, and associated outcomes with IVUS use during peripheral arterial intervention. JACC Cardiovasc Interv. 2022;15(20):2080-2090. doi: 10.1016/j.jcin.2022.07.050. PMID: 36265940.