Noting the challenges with angiography in the imaging of lower extremity revascularization, a panel of interventional radiologists, interventional cardiologists and vascular surgeons discussed emerging evidence that supports the use of intravascular ultrasound in facilitating improved outcomes in this high-risk patient population.
In a recently published multidisciplinary roundtable discussion including interventional radiologists, vascular surgeons and interventional cardiologists, researchers discussed emerging evidence and key considerations with the use of intravascular ultrasound for peripheral vascular interventions in the lower extremity.
Here are eight takeaways from the roundtable discussion consensus, which was recently published in three journals, including the Journal of Vascular and Interventional Radiology (JVIR).
1) In a comparison of intravascular ultrasound (IVUS) and angiography for assessing vascular characteristics, the panelists noted that IVUS was deemed to have “excellent” performance in 12 out of 13 characteristics including assessment of stent sizing, stenosis, lesion length and plaque burden. Angiography had “good” performance for five characteristics and “fair” quality for six characteristics. Angiography was only deemed “excellent” for assessing vascular flow in contrast to a “fair” rating for IVUS.
2) Citing a study of over 540,000 peripheral arterial interventions performed over a three-year period for Medicare beneficiaries and a median follow-up of more than 500 days, the panelists noted the use of IVUS “was associated with a 27% reduction in the risk for major adverse limb events.” They also noted 18 percent and 31 percent reductions in risk for acute limb ischemia and major amputation respectively.
3) In a prospective trial comparing angiography to the combination of angiography and IVUS in 150 patients who had femoropopliteal endovascular intervention, researchers found that adjunctive IVUS resulted in a 17 percent higher rate of freedom from binary restenosis at one year (72.4 percent vs. 55.4 percent) and facilitated treatment plan changes in 78.9 percent of cases.
4) The panel pointed out that IVUS-guided stenting reduced one-year post-op rates of stent migration, re-intervention, and hospitalization according to a 2022 retrospective study of Medicare patients who had deep venous stent placement procedures.
5) There was a 20 percent increase in the use of IVUS by interventional radiologists for arterial interventions in Medicare beneficiaries between 2016 and 2019.
6) In contrast to a 24 percent increase in IVUS use in arterial interventions at ambulatory surgery centers and office-based laboratory settings between 2016 and 2019, the panel pointed out that IVUS only had a marginal increase in usage during this time period for inpatient and hospital outpatient procedures.
“This may be due to hospital-based physicians not having ready access to developing technology due to the increased pressures from hospital administrators to not increase capital expenditures and the lack of additional reimbursement within the diagnosis-related group (DRG) system,” wrote lead author Eric A. Secemsky, M.D., MSc, the director of vascular intervention at the Beth Israel Deaconess Medical Center (BIDMC), and section head of interventional cardiology and vascular research at the Richard A. and Susan F. Smith Center for Outcomes Research at BIDMC in Boston, and colleagues.
7) While acknowledging the value of IVUS for localizing and measuring the size of lesions and orifices, the panelists conceded current challenges with the modality for identifying vulnerable plaque due to resolution issues, a lack of consistency with border detection and a lack of accuracy with tissue definition.
8) Noting a lack of standardized education for the use of IVUS in peripheral interventions, the panelists noted that only 15 percent of cardiology trainees express confidence in using IVUS independently. They emphasized the importance of multifactorial and interdisciplinary training to bolster the knowledge and use of IVUS, and also suggested that formal certification may improve IVUS-guided decision-making.