Should Interventional Radiologists Incorporate Intravascular Ultrasound (IVUS) Into Their Daily Practice? A...

To provide a systematic review and meta-analysis of studies comparing intravascular ultrasound (IVUS)-guided versus angiography-guided peripheral vascular interventions (PVI) for peripheral arterial disease (PAD).

We performed a systematic review and meta-analysis, following PRISMA guidelines, of studies comparing IVUS-guided versus angiography-guided PVI for peripheral arterial disease (PAD). The study was registered in PROSPERO (CRD42024564731). Relevant databases were searched until Dec 2025. Eligible studies reported at least one of the following outcomes: amputation, all-cause mortality, target lesion revascularisation (TLR), restenosis/occlusion, major adverse limb events (MALE), or technical success. Random-effects models with inverse-variance weighting were used to generate pooled effect estimates.

Twenty-five studies (23 observational, 2 randomised) including 1,110,593 patients (93,977 IVUS; 1,016,616 angiography) met inclusion criteria. Compared with angiography, IVUS guidance was associated with reduced rates of amputation (RR = 0.75, 95% CI for RR 0.61-0.93), all-cause mortality (RR = 0.86, 95% CI for RR 0.79-0.93), TLR (RR = 0.66, 95% CI for RR 0.48-0.91) and restenosis (RR = 0.74, 95% CI for RR 0.60-0.90). A numerically lower rate of major adverse limb events (MALE) was observed with IVUS guidance, although confidence intervals crossed the null effect (RR 0.66, 95% CI for RR 0.40-1.10). Technical success rates were similar between groups (RR 1.01, 95% CI for RR 1.00-1.01).

IVUS-guided PVI was associated with lower rates of amputation, TLR, restenosis, and all-cause mortality compared with angiography alone. However, the available evidence is predominantly observational with low-to-moderate certainty. These findings suggest potential benefit of IVUS-guided intervention in PAD, although further randomised controlled trials are needed.