Intravascular Ultrasound for Lower Extremity Interventions: Seven Takeaways from New Global Consensus Recommendations

In newly published global consensus recommendations, leading vascular experts recommended intravascular ultrasound (IVUS) for all phases of interventional procedures for tibial arteries as well as iliofemoral venous interventions. The expert guidance also noted that IVUS is appropriate for most pre-op workup, intraprocedural and post-op optimization phases of iliac and femoropopliteal revascularization.

Given the prevalence of peripheral vascular disease, which reportedly affects up to 45 million Americans, and an evolving evidence basis for the use of IVUS in lower-extremity interventional procedures, Sahil Parikh, M.D., a co-author of the recommendations, said the consensus guidance may provide more consistency with the use of the modality.

“Lack of clarity in the appropriate use of IVUS in peripheral vascular procedures has raised important questions in daily interventional practice,” said Dr. Parikh, the director of endovascular services at the Columbia University Irving Medical Center. “Establishing the appropriate use criteria recommendations is a historical milestone and foundational step towards improving the quality and safety of peripheral vascular procedures.”

The consensus recommendations, published in JACC: Cardiovascular Interventions, were drawn from two surveys on arterial interventional scenarios in the lower extremity and iliofemoral venous interventional procedures. Each of the surveys was completed by 15 global vascular experts, according to the guidance.

“They recommend routine use of IVUS as a preferred imaging modality in all phases for many peripheral interventions, both diagnostic and therapeutic, as it enables such exquisite visualization of the target vessel and lesion,” noted lead author Eric A. Secemsky, M.D., an assistant professor of medicine at Harvard Medical School and an interventional cardiologist at the Beth Israel Deaconess Medical Center in Boston. “(The) recommendations, which withstood the rigor of peer review, can now be considered in the formulation of clinical guidelines for the diagnosis and treatment of peripheral vascular disease.”

Here are a few takeaways from the consensus recommendations.

1) Prior to the use of devices such as stents, the consensus authors noted the use of IVUS can help identify the need for vessel preparation. Intraoperative IVUS guidance may decrease the risk of stent failure by facilitating optimal sizing and subsequent expansion of the stent, according to Secemsky and colleagues.

2) In comparison to venography alone, the consensus experts said IVUS offers better visualization of maximal stenosis and ascertaining the presence of extrinsic vascular compression. Noting that IVUS is increasingly being considered as part of the standard of care during deep venous intervention procedures, the guidance authors added that IVUS is beneficial in assessing pre-op and post-op thrombus burden for patients requiring iliofemoral venous interventions.

3) Prior to iliac artery revascularization procedures, Secemsky and colleagues noted that IVUS is appropriate for assessing the severity of ambiguous lesions, vessel sizing and reducing the use of contrast.

4) Prior to deep venous intervention, the consensus experts deemed IVUS appropriate for assessing lesion characteristics and severity, filling defects, vessel sizing and reducing contrast use.

5) For iliac and femoropopliteal artery segments, Secemsky and colleagues maintained that “IVUS was consistently appropriate when used during the intraprocedural and post-intervention optimization phases … .”

6) The consensus authors noted that IVUS may be appropriate for assessing occlusion and plaque morphology prior to femoropopliteal interventions.

7) Studies have shown the use of IVUS reduces the risks of in-stent restenosis and stent migration with deep venous interventional procedures by improving the pre-op assessment of lesion and vessel characteristics, according to the consensus experts.

In regard to limitations with the expert guidance, the authors emphasized that future studies are needed to assess the use of IVUS on targeted revascularization procedures in the lower extremity and its long-term impact in reducing major adverse limb events. Research is also needed to gauge cost considerations with the addition of IVUS to the workup and performance of peripheral vascular interventions in the lower extremity, according to the expert panel.