Meta-analysis of Intravascular Ultrasound-guided versus Angiography-guided Endovascular Treatment in Lower Extremity Artery Disease

Intravascular ultrasound (IVUS) offers precise information about lesion morphology and enhance the optimization of endovascular treatments (EVT). Nevertheless, the impact of IVUS on the durability of EVTs and clinical outcomes remains uncertain. The aim of this systematic review and meta-analysis was to evaluate the efficacy of IVUS-guided EVT compared with angiography-guided EVT. We conducted a meta-analysis of trials comparing IVUS-guided and angiography-guided EVT. The primary endpoint was binary restenosis, while the secondary endpoints included reintervention, major amputation, death or amputation, and major adverse limb events (MALE). This meta-analysis included 19 studies with 800,452 patients. Compared to angiography-guided EVT, IVUS-guided EVT significantly reduced the risk of binary restenosis (RR: 0.63, CI: 0.43-0.91, p=0.02). It also reduced the risk of reintervention (RR: 0.59, CI: 0.39-0.90, p=0.01), major amputation (RR: 0.85, CI: 0.74-0.98, p=0.02), death or amputation (RR: 0.72, CI: 0.56-0.91, p=0.007), and MALE (RR: 0.52, CI: 0.28-0.94, p=0.03). Subgroup analysis for femoropopliteal disease revealed consistent benefits of IVUS guidance regarding binary restenosis (RR: 0.63, 95% CI: 0.42-0.94, p=0.03), reintervention (RR: 0.51, CI: 0.33-0.80, p=0.003), major amputation (RR: 0.85, CI: 0.73-0.99, p=0.04), death or amputation (RR: 0.68, CI: 0.51-0.90, p=0.007), and MALE (RR: 0.51, CI: 0.27-0.96, p=0.04). The sensitivity analysis of studies using drug-coated device also showed the consistent benefit of IVUS guidance regarding binary restenosis. In conclusion, compared to angiography, IVUS-guided EVT provided improved clinical outcomes in terms of binary restenosis, reintervention, major amputation, death or amputation, and MALE in lower extremity artery disease, including femoropopliteal disease.