Intravascular Ultrasound in the Endovascular Treatment of Patients With Peripheral Arterial Disease: Current Role and Future Perspectives

Abstract

Over the last decade, intravascular ultrasound (IVUS) has emerged as a useful adjunctive tool to angiography in an increasing number of catheter-based procedures for peripheral arterial disease (PAD). IVUS catheters offer accurate cross-sectional imaging of arterial vessels with high dimensional accuracy and provide accurate information about lesion morphology. IVUS enables assessment of the plaque morphology, vessel diameter, and the presence of arterial dissections. Furthermore, IVUS is able to properly guide the best choice of appropriate percutaneous transluminal angioplasty (PTA) technique, guide the delivery of different devices, and assess the immediate result of any endovascular intervention. In the present review, the role of IVUS for PAD will be discussed, specifically the applications of IVUS technology during interventional procedures including PTA, stent sizing, crossing total occlusion, assessing residual narrowing and stent apposition and expansion, and atherectomy. Future perspectives of IVUS-guided treatments and cost-effectiveness of the systematic use of IVUS during endovascular interventions will be also discussed.

Keywords: atherectomy; intravascular ultrasound (IVUS); percutaneous transluminal angioplasty (PTA); peripheral arterial disease; stent placement.

Figure 1

Commonly used peripheral vascular intravascular ultrasound catheter. It comes on a 0.014- or 0.035-inch guidewire with monorail system.

Figure 2

Limping patient of 67-year old. (a) Antegrade angiography by common femoral approach shows pre-occlusive calcified stenotic lesion of the mid and distal part of the right superficial femoral artery. (b) Atherectomy with the Phoenix device. (c) Control after atherectomy shows lumen gain. (d) Control after conventional PTA demonstrates no residual stenosis. (e) Result after application of drug-coated balloon shows no significant focal residual stenosis (arrow). (f) Checking with a 0.014-inch IVUS catheter. (g–i) IVUS demonstrates very well a focal intimal dissection post-angioplasty at the level of the focal residual stenosis, not visible at angiogram (arrows). (j–l) Result after spot stenting. (m,n) Final IVUS control shows normal arterial lumen with stent patency.

Figure 3

72-year old patient with right claudication. (a) Angiogram by crossover shows important calcified stenotic lesions of the right common femoral artery (arrow). (b,c) IVUS confirms the large circonferential hyperechogenic calcifications (arrows). (d) Use of JetStream atherectomy device for debulking. (e) Result after debulking shows lumen gain. (f) Conventional PTA and drug-coated balloon angioplasty. (g) IVUS control confirms the excellent debulking result with removal of calcifications and lumen gain. No additional stenting was needed. (h) Final result at angiogram demonstrates normal lumen size with no residual stenosis.