Editor's Choice - Intravascular Ultrasound Guided Endovascular Therapy for Femoropopliteal Disease: A Systematic Review and Meta-analysis.

Abstract

This study aimed to evaluate the clinical benefits of intravascular ultrasound (IVUS) vs. angiography guidance in endovascular therapy through systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library from inception through to 1 August 2024. Relevant randomised controlled trials (RCTs) and observational studies comparing IVUS and angiography guided endovascular therapy for femoropopliteal disease were included if they reported at least one pre-specified 12 month outcome. Study quality and certainty of evidence were assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The primary endpoints were primary patency and freedom from clinically driven target lesion revascularisation (CD-TLR). Secondary endpoints included freedom from major amputation and overall survival. Of the 5 819 identified articles, 12 studies involving 9 873 patients were included. IVUS guidance was associated with a statistically significantly higher odds of primary patency (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.24 - 2.12; p < .001) and freedom from CD-TLR (OR 2.29, 95% CI 1.59 - 3.29; p < .001) compared with angiography guidance, while heterogeneities were significant. IVUS guidance improved primary patency rates in RCTs (OR 2.10, 95% CI 1.31 - 3.38; p = .002) and in propensity score matched observational studies (OR 1.60, 95% CI 1.03 - 2.49; p = .040). CD-TLR outcomes were also favourable in propensity score matched (OR 2.30, 95% CI 1.09 - 4.83; p = .030) and unmatched (OR 2.53, 95% CI 1.67 - 3.83; p < .001) observational studies. No statistically significant differences were observed in secondary endpoints. The overall risk of bias was high, and the certainty of evidence was low, largely due to the inclusion of observational studies. IVUS guidance may enhance primary patency and reduce re-intervention after endovascular therapy for femoropopliteal disease. Owing to study limitations, these findings should be interpreted with caution.