Intravascular Ultrasound versus Angiography for Lower Extremity Peripheral Artery Disease Endovascular Revascularization: A Systematic Review and Meta-Analysis
In brief
Intravascular ultrasound cuts restenosis risk by roughly 40% in PAD procedures
A meta-analysis of two randomized trials (387 patients) found IVUS guidance lowered restenosis rates to about 60% of those seen with angiography alone, with moderate certainty. The same trials did not show clear reductions in repeat procedures, major amputation, or death, and observational data suggesting broader benefits remain low-certainty, underscoring the need for larger RCTs.
- Journal
- Journal of vascular surgery (Q1)
- Published
- 3 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Marc-André d'Entremont, Graham R McClure, Krzysztof Kowalik, Eric A Secemsky, Samuel Lemaire-Paquette, Laura M Drudi, et al.
- PMID
- 42546858
- DOI
- 10.1016/j.jvs.2026.06.180
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 9 August 2026).
- Picked for Surgery (top studies of the week, 9 August 2026): Systematic review/meta‑analysis of IVUS vs angiography for PAD endovascular revascularization
Abstract
OBJECTIVE: We aimed to conduct a systematic review and study-level meta-analysis of randomized controlled trials and observational studies comparing intravascular ultrasound (IVUS) guidance with angiography guidance for peripheral artery disease (PAD) endovascular revascularization, as current evidence is lacking. METHODS: We searched Medline, Embase and CENTRAL from inception until November 22, 2025. Trials and observational studies were analyzed separately. We used random-effects as our primary analysis and assessed the certainty of evidence using GRADE. Key outcomes included restenosis, reintervention, major amputation, and mortality. RESULTS: We included 2 randomized trials (n = 387), and 19 observational studies (n = 1,164,329). According to randomized data, IVUS-guidance likely reduces restenosis compared to angiography-guidance (RR 0.59, 95% CI 0.42 - 0.83; moderate certainty). However, IVUS may not reduce reintervention (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.44 - 1.08, low certainty), or mortality (RR 1.13, 95% 0.37 - 3.42, low certainty), while its effect on major amputation is very uncertain (RR 0.97, 95% 0.14 - 6.73, very low certainty). However, based on observational data, IVUS may reduce restenosis (RR 0.70, 95% CI 0.54 - 0.90, low certainty), reintervention (RR 0.66, 95% CI 0.48 -0.90, low certainty), major amputation (RR 0.83, 95% CI 0.72 - 0.96, low certainty), and mortality (RR 0.88, 95%CI 0.84, 0.93, low certainty). CONCLUSION: IVUS guidance likely reduces restenosis based on limited randomized evidence. Observational studies suggest potential benefits across several outcomes, although the certainty of evidence is low. Larger randomized trials are required to clarify the potential benefits of IVUS guidance.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.