Cutting-edge progress of intravascular ultrasound in lower-extremity vascular interventions

Article information

Ultrasonography. 2025;44(1):5-18

Publication date (electronic) : 2024 September 25

doi : https://doi.org/10.14366/usg.24148

Xin Guan

, Hong Han

, Huixiong Xu

Department of Ultrasound, Institute of Ultrasound in Medicine and Engineering, Zhongshan Hospital, Fudan University, Shanghai, China

Correspondence to: Huixiong Xu, MD, PhD, Department of Ultrasound, Institute of Ultrasound in Medicine and Engineering, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, P. R. China Tel. +86-021-31243722 Fax. +86-021-64041990 E-mail: xuhuixiong@126.com

Received 2024 August 4; Revised 2024 September 24; Accepted 2024 September 25.

Abstract

Lower-extremity vascular disease has a high morbidity rate and often leads to disability and death in its advanced stages. Although angiography-guided endovascular intervention is the primary treatment for peripheral vascular disease, it frequently fails to detect subtle lumen features and falls short of meeting the increasing clinical need for precise management. Intravascular ultrasound (IVUS) merges noninvasive ultrasound imaging with invasive catheterization techniques, providing 360° imaging of the vascular cross-section and delivering accurate information about lesion morphology. IVUS has been crucial in supporting decision-making for preoperative assessment, intraoperative monitoring, and postoperative optimization during vascular interventions. This review aims to summarize the latest applications of IVUS in lower-extremity vascular disease, discuss its strengths and limitations, and explore future directions for its use.

Keywords: Interventional ultrasonography; Lower-extremity vascular disease; Endovascular therapy; Atherosclerosis; Venous thrombosis

Introduction

Peripheral vascular disease is a chronic limb ischemic condition that includes vascular diseases other than those affecting the cardiovascular and cerebrovascular systems. Notably, lower-extremity vascular disease (LEVD) impacts over 230 million adults globally and is linked to an increased risk of various adverse clinical outcomes [1]. With advances in interventional techniques, endovascular therapy (EVT) has become the preferred treatment for patients with LEVD, except in cases of overly complex lesions [2]. Although angiography remains the primary method of image guidance during peripheral interventions, it has its limitations. Angiography mainly reveals the overall vascular morphology and structure, which can be difficult to interpret in cases of vascular tortuosity and may not fully capture the extent of complex and eccentric lesions [3]. Therefore, there is an urgent need to develop new techniques that offer high-resolution visualization of lumen morphology and lesion characteristics to fulfill the requirements of precise clinical diagnosis and treatment.

Intravascular ultrasound (IVUS) is a technique that combines catheterization and ultrasound (US) imaging. It involves inserting a miniature US transducer into the vessel lumen via a catheter, which then scans 360° to enable US imaging of vascular structures [4]. IVUS offers several unique advantages over the gold standard invasive angiography and the more commonly used computed tomography angiography (CTA). It provides real-time visualization of vascular morphology, lesion properties, and distribution within the vessel wall. IVUS enables accurate assessment of stenosis by measuring the vessel’s inner diameter or cross-sectional area (CSA), and it can identify lesions such as calcification, fibrosis, or lipid pools. It also detects early vascular lesions that are not visible by angiography and recognizes intravascular tissues and devices such as thrombi, stents, and guidewires. Additionally, the adjunctive use of IVUS during EVT can significantly reduce the need for iodinated contrast agents, decrease radiation exposure, and shorten procedure times in certain cases [5]. Currently, the use of IVUS in the coronary field is well-established, while its application in LEVD is still emerging [6]. To date, there are limited prospective studies or trials comparing outcomes between angiography-guided and IVUS-guided LEVD interventions, with most evidence derived from retrospective observational cohort studies [7]. Given that peripheral vessels are larger and longer than coronary vessels and are more prone to developing lesions, the application of IVUS in the LEVD field holds great promise.

In this review, we provide a comprehensive overview of the current applications of IVUS in managing LEVD, which includes both peripheral arterial disease (PAD) and peripheral venous disease (PVD) (Fig. 1). We also discuss the key advantages and limitations of IVUS in these contexts and explore potential future developments in this field.

Fig. 1.

Intravascular ultrasound systems as an auxiliary imaging technique in the endovascular treatment of lower-extremity vascular diseases.

EVT, endovascular therapy; PAD, peripheral arterial diseases; PTA, percutaneous transluminal angioplasty; PVD, peripheral venous diseases.

Imaging Principles of IVUS Systems

The IVUS system typically comprises a console, an automatic pullback device, and an imaging catheter [4]. At the catheter's tip, the transducer receives an electrical signal from the console. This signal activates the piezoelectric crystals within the transducer, causing them to expand and contract, thereby generating high-frequency US waves. These waves scatter and reflect off tissue interfaces, with some of the reflected waves being converted back into electrical signals by the transducer. These signals are subsequently analyzed and processed by the imaging engine in the console, resulting in grey scale cross-sectional images.

Requirements for Peripheral IVUS Catheters

The technical parameters of peripheral IVUS catheters vary moderately from those of coronary IVUS catheters, reflecting differences in vascular characteristics. Thicker peripheral vessels necessitate the use of larger catheter sizes and corresponding sheaths, with guidewires that may exceed 0.035 inches. In contrast, smaller vessels in the subinguinal region require finer guidewires, typically 0.018 or 0.014 inches in diameter. IVUS catheters are available in lengths ranging from 90 to 150 cm, facilitating imaging of the infra-popliteal artery through a contralateral approach [7,8]. To effectively differentiate between plaque and the peripheral vessel wall, IVUS transducers operating at frequencies between 20 and 60 MHz are commonly used [9]. This frequency range allows for an axial resolution of 20-100 μm, a lateral resolution of 150-250 μm, and a penetration depth of 6-15 mm, providing detailed imaging necessary for accurate assessments [10].

Imaging Interpretation

Normally, images acquired by a console display the catheter within the vessel lumen, alongside a triple-layered vessel membrane structure (Fig. 2). The anechoic ring-like structure inside the lumen represents the media, while the hyperechoic areas indicate the intima and adventitia. As the IVUS catheter is retracted, it typically converges into the main branch lumen, displaying an "8" shaped or gourd-like appearance. Under pathological conditions, IVUS can identify plaques with different characteristics. Lipid-rich plaques appear as predominantly hypoechoic black areas, whereas densely organized fibrous plaques present as brighter areas. Calcified plaques, specifically, are the brightest hyperechoic plaques and are often accompanied by posterior acoustic shadows. In cases of stent thrombus, these commonly manifest on IVUS as a slightly hypoechoic mass within the lumen, accompanied by speckled or scintillating images. Notably, old thrombi are difficult to distinguish from fibrous plaques, as retraction and mechanization enhance their echogenicity. Dissection appears as a circular tear in the vessel wall, presenting as anechoic or hypoechoic areas. Intramural hematomas, a variant of dissection, appear as a crescent-shaped hypoechoic or isoechoic area within the media.

Fig. 2.

Schematic diagrams and real images illustrating normal anatomy and pathological conditions as visualized by intravascular ultrasound.

IVUS, intravenous ultrasound.

Before measurements can be taken, it is essential to determine the lumen boundary. The most commonly used radial diameters include the boundary between the intima and the lumen, as well as the boundary between the media and the adventitia, also known as the external elastic membrane (EEM). Parameters such as minimum lumen CSA, minimum and maximum lumen diameter, lumen eccentricity, lumen stenosis area, and plaque area can be directly measured from IVUS images. This allows for precise localization and measurement of plaque or thrombus, which is crucial in determining whether to perform procedures like balloon or primary stent placement in stenotic or occluded arterial lesions. It is important to note that the vessel area was measured from the media layer, due to the challenges in identifying the intima on IVUS images. Additionally, vessel measurements typically include three segments: proximal, lesion site, and distal. The reference vessel diameter is selected from a plaque-free, smooth segment of the intima.

Application of IVUS in Lower-Extremity PAD

Currently, the use of IVUS in lower-extremity PAD involves the aortoiliac artery, iliac artery, superficial femoral artery, femoropopliteal artery, and infrapopliteal artery. The related research scenarios include percutaneous transluminal angioplasty (PTA), stenting, atherectomy, drug-coated balloons, and true lumen reentry. A summary of the major prospective studies evaluating IVUS for lower-extremity PAD is provided in Table 1 [11-21]. In brief, during the perioperative period, IVUS can be used to identify situations that may require vessel preparation or stenting. During interventions, IVUS can detect issues such as stent apposition or under-expansion, and procedural complications not recognized by angiography. In post-intervention scenarios, IVUS aids in evaluating residual stenosis or plaque after debulking, optimizing stenting, and detecting dissection. These advantages make IVUS a favorable complement to angiography, potentially leading to improvements in procedural safety and long-term outcomes.

Table 1.

Summary of main prospective studies assessing IVUS for lower-extremity PAD

Pre-intervention Scenarios: Vascular Properties

The use of preoperative IVUS during lower-extremity PAD has shown improved accuracy in assessing vessel diameter and hemodynamic significance, surpassing that of angiography alone [3]. Typically, angiography is regarded as the gold standard for estimating vessel size and for EVT. However, it has several inherent limitations, including providing only a two-dimensional image of a three-dimensional luminal structure, difficulty in recognizing intravascular structures, and susceptibility to confounding artifacts caused by arterial wall motion [12,22]. In contrast, IVUS offers a real-time cross-sectional image of the vessel, clearly depicting the thickness of the vessel wall as well as the size and shape of the lumen, which allows for accurate measurements of vessel lumen diameter and CSA. A comparative analysis of angiography versus IVUS in evaluating peripheral atherosclerosis revealed that although angiography is highly reliable for quantitative intraluminal assessment, its measurements of true vessel diameter, actual stenosis area, calcification, and plaque concentricity were significantly inconsistent with those obtained from IVUS [12]. Similarly, a prospective study by Shammas et al. [19] showed that the mean vessel diameter of the infrapopliteal artery measured by IVUS was approximately 25% larger than that measured by angiography. In the assessment of femoral and iliac arteries, IVUS demonstrates comparable accuracy to CTA but offers advantages in reducing the use of contrast agents and exposure to radiation. IVUS can be a valuable adjunct to CTA, particularly in patients with poor femoral artery diameters or extensive artifacts on CTA [23]. Additionally, IVUS has shown strong intra- and inter-observer agreement in measuring parameters such as lumen CSA, EEM CSA, luminal diameter, and reference vessel diameter, further supporting its utility in peripheral arterial procedures [21].

Pre-intervention Scenarios: Plaque Morphology

Compared to angiography, IVUS can more precisely determine the type (e.g., soft, fibrous, calcified, or mixed) and morphology (e.g., shape, length, volume, eccentric or concentric) of plaques [24]. The introduction of virtual histology IVUS, which analyzes additional low radiofrequency signals, allows for an enhanced assessment of the histological composition of arterial plaques [7]. Both the type and location of the plaque influence the choice of procedure and the outcome of EVT. IVUS has been utilized to assess lesion volume and composition before and after atherectomy, as well as to predict the risk of amputation [25,26]. According to the plaque echo intensity characteristics on IVUS, hypoechoic plaques, typically laden with a higher lipid content, are prone to exhibit no or slow blood flow post-intervention, necessitating increased vigilance during the procedure. Furthermore, IVUS enables the differentiation between superficially calcified plaques, which may undergo more aggressive pre-dilatation, and deeply calcified plaques, where simpler pre-dilation techniques or a cutting balloon are preferred [27].

Pre-intervention Scenarios: Calcium Severity

Angiography underestimates the degree of calcification within a vessel because it only reveals calcification on one or both sides of the arterial wall and fails to accurately identify intimal or medial calcification [22]. In contrast, IVUS is more sensitive in detecting the presence and severity of vessel wall calcification [16]. The characteristics of calcification identified by IVUS have been strongly linked to the patency rate following EVT [28]. Fujihara et al. [29] demonstrated that a calcification angle greater than 180°, as assessed by IVUS, was associated with a smaller postoperative minimum lumen area, indicating challenges in successfully dilating the lesion. Similarly, a prospective multicenter study on femoropopliteal lesions found that a smaller calcification angle detected by IVUS correlated with higher vascular patency after PTA [18].

Pre-intervention Scenarios: Thrombi

The echogenicity of older, mechanized thrombi on IVUS resembles that of fibrous plaques, while fresh, acute thrombi appear hypoechoic due to their high erythrocyte concentration and low fibrin content [7]. Although IVUS identifies more lower-extremity arterial thrombi than angiography, its capacity to differentiate stages of thrombus development is constrained by its lower resolution [30].

Intra-procedure Scenarios

IVUS, as an adjunctive imaging technique, enhances the safety and efficacy of EVT by providing accurate lesion characterization and guiding stent deployment to optimize therapeutic strategies (Fig. 3) [31]. Although PTA or stenting can improve vessel patency in arterial occlusive lesions, they also carry risks such as early thrombosis or stent migration due to inadequate expansion, and intimal hyperplasia or vessel perforation from overexpansion. The ability of IVUS to precisely assess vascular structure and lesion characteristics not only enables a precise pre-procedural diagnosis but also guides the selection of appropriate interventions and assists in the accurate deployment of endovascular devices. Compared to angiography, several studies have shown that incorporating IVUS during endovascular procedures for lower-extremity arterial disease improves long-term clinical outcomes, including higher primary patency rates, lower complication rates, and reduced restenosis rates [20,32,33]. There was no significant difference between the two approaches in terms of technical success or procedure time. During lesion debulking or atherectomy for peripheral arterial occlusive disease, IVUS helps orient the cutting blade to ensure adequate plaque removal and prevent vessel perforation, leading to improved revascularization rates and fewer complications [17,34]. IVUS also aids in identifying patients who may benefit more from atherectomy than from standard PTA. In cases of IVUS-guided true lumen reentry, a satisfactory clinical success rate was achieved regardless of the catheter used [35-37]. Mori et al. [38] demonstrated that a higher percentage of intraplaque routes resulted in higher primary patency and a restenosis rate of only 9% during follow-up. Meanwhile, IVUS-guided percutaneous bypass could be feasible for treating patients with an uncrossable superficial femoral artery [39]. In patients with pre-existing renal insufficiency, IVUS can avoid the use of nephrotoxic contrast agents [13]. More importantly, IVUS-guided interventions were associated with lower target lesion revascularization, which improved outcomes and reduced costs in the long run, highlighting IVUS as an overall cost-saving strategy [40].

Fig. 3.

A 65-year-old woman with lower-extremity atherosclerotic occlusive disease.

A. Preoperative intravascular ultrasound (IVUS) demonstrates luminal stenosis and mixed plaque. B. IVUS after balloon dilatation shows localized dissection. C. IVUS after stent implantation displays favorable lumen gain.

Post-intervention Optimization Scenarios: Stent Optimization

Several studies have demonstrated that IVUS can identify previously inadequate stent deployments that were considered sufficiently expanded by angiography, influencing changes in the treatment plan [41,42]. For instance, research on EVT for atherosclerotic aortoiliac occlusive disease found that IVUS detected inadequately deployed stents, which angiography had deemed adequately dilated, in about 40% of patients [43].

Post-intervention Optimization Scenarios: Dissection Detection

Higher-level dissection is associated with increased rates of target lesion revascularization and decreased lumen patency rates [44]. Precise imaging within the vessel wall is essential to accurately assess the extent and severity of vessel dissection (Fig. 4) [24]. Angiography often underestimates both the presence and severity of vascular dissections following EVT, typically resulting in the selection of treatment segments that are too small. IVUS not only identifies more severe dissections than those detected by angiography but also reveals dissections that angiography does not detect [19]. The ability of IVUS to diagnose dissections has been demonstrated in most arteries of the lower extremities [11,17,19,36,37]. A prospective study that employed atherectomy and angioplasty for treating femoropopliteal artery lesions found that IVUS detected 3.55 times as many vascular dissections as angiography, with about one-third of these dissections involving the intima or media [45]. Currently, there are no standardized criteria for classifying dissections in lower-extremity arteries. Furthermore, it remains unclear which dissections identified by IVUS should be managed and whether IVUS should be used to guide the repair of these dissections. Therefore, large-scale samples and prospective clinical studies are still required.

Fig. 4.

A 67-year-old man with claudication.

A. Antegrade angiography shows a pre-occlusive calcified stenotic lesion in the mid and distal parts of the right superficial femoral artery. B. Post-atherectomy imaging displays lumen gain. C. Post-percutaneous transluminal angioplasty imaging shows no residual stenosis (arrow). D. Intravascular ultrasound (IVUS) clearly exhibits focal intimal dissection at the level of residual stenosis post-angioplasty, which is not visible on the angiogram (arrow). E. The results after using a drug-coated balloon show no significant focal residual stenosis. F. The final follow-up IVUS shows a normal arterial lumen with stent patency. Reproduced from Loffroy et al. Front Cardiovasc Med 2020;7:551861, according to Creative Commons Attribution License [24].

Post-intervention Optimization Scenarios: Long-Term Outcomes Prediction

The risk of restenosis following EVT has been associated with IVUS findings observed during the intervention. These findings provide valuable information for postoperative follow-up and surveillance [14,15]. Factors such as a large distal plaque burden, minimal lumen area, and a significant maximal dissection angle post-intervention on IVUS have been identified as predictors of restenosis after EVT [18,46-48].

Application of IVUS in Lower-Extremity PVD

In the lower-extremity venous system, IVUS is currently employed to address obstructive lesions in the iliofemoral vein segment. Table 2 [49-56] lists the principal studies that evaluated the use of IVUS in treating lower-extremity PVD. While IVUS can also assess obstructions in the inferior vena cava and left renal vein, these applications are beyond the scope of this review. IVUS facilitates the detailed identification of peripheral venous pathology, including acute inflammatory venous wall thickening, thrombosis, chronic stenosis, valvular dysfunction, and fibrosis. This detailed assessment helps determine the underlying cause of the disease and develop targeted intervention strategies to improve patient outcomes.

Table 2.

Summary of main studies assessing IVUS for lower-extremity PVD

Pre-intervention Diagnosis

An appropriate clinical evaluation of patients before intervention procedures is crucial to identify those who might benefit from treatment, as iliac vein compression can often be asymptomatic. IVUS reveals findings that are not detectable by single-plane venography and has proven to be superior in assessing the morphology of stenosis (Fig. 5). Indeed, IVUS is more effective at detecting obstructive lesions than venography, which often fails to recognize severe obstructions [50,52,53]. When compared to venography, CTA provides a diagnostic capability similar to that of IVUS for identifying lower-extremity venous stenosis or obstruction [55,57]. In cases of iliac vein obstruction, IVUS can detect detailed intraluminal and mural features such as mural thickness, trabeculation, frozen valves, and external compression, thus effectively preventing blind stenting [49]. Additionally, IVUS can distinguish between acute thrombosis and iliac vein compression lesions, allowing for the selection of appropriate treatment based on the lesion's characteristics [58]. A fresh thrombus requires thrombolysis, whereas iliac vein compression may necessitate PTA/stent placement. IVUS also enables the quantification of thrombus volume, providing a precise clinical basis for the aspiration of iliac vein thrombi.

Fig. 5.

A 30-year-old woman with May-Thurner syndrome.

A. Axial computed tomography shows significant narrowing of the left iliac vein (arrow) because it courses posterior to the right common iliac artery (black arrow) consistent with May Thurner Syndrome. B. Left iliac vein contrast venography with the patient in the prone position from the popliteal vein showing obstruction of the common iliac vein (arrow) from extrinsic compression. C. Venography during venoplasty shows the left common iliac vein stenosis position (arrow) manifested as an obvious waist on the balloon. D. Venography after stent implantation shows left iliac vein patency with venous collateral branch loss. E. Intravascular ultrasound displays significant lumen narrowing (arrow) before stenting of the left common iliac vein. F. Intravascular ultrasound displays a widely patent lumen (arrow) after stenting with representative stent struts (arrowheads). Reproduced from Marteslo et al. Ultrasound Med Biol 2020;46:216-224, with permission of Elsevier [5].

Intra-procedure Planning

IVUS is more accurate than venography in determining the appropriate stent diameter, length and number. A comparative study of venogram and IVUS in diagnosing iliac vein obstruction revealed that IVUS identified more significant lesions that were not detected by conventional venography. This led to changes in treatment approaches and an increase in the number of stents used [53]. Meanwhile, IVUS can clearly identify the anatomical structures where the lesion is located, enabling more accurate stent deployment. Another study highlighted that IVUS more effectively identified maximal area stenosis, its anatomical location, the ilio-caval confluence, and the distal landing zones [59].

Post-intervention Optimization

IVUS is instrumental in identifying significant complications, such as grading the severity of residual lesions, stratifying thrombus, and ensuring proper stent apposition. Traditionally, venography has been regarded as the gold standard for assessing the effectiveness of pharmacomechanical thrombectomy. However, it tends to overestimate thrombus removal due to factors such as contrast agent stasis within the thrombus, obstructive anatomy that masks underlying venous lesions, reduced visibility in obese patients, and the limitation of providing only two-dimensional views of three-dimensional structures [51]. IVUS excels in imaging the interface between blood, thrombus, and the lumen wall, and it can diagnose external compression and residual stenosis. This capability allows it to identify inadequate thrombolysis that might be missed when guided solely by venography [51,60]. IVUS helps to visualize residual obstruction areas that are poorly depicted by venography and is more accurate in evaluating the apposition of adjacent stents [56]. Raju et al. [61] demonstrated that stent over-dilatation guided by IVUS resulted in more durable improvements in caliber and better clinical outcomes (Fig. 6). Additionally, IVUS is useful for longitudinal assessments post-EVT when noninvasive imaging is not indicated. This includes assessing the long-term patency of iliac vena cava stents in patients with chronic venous insufficiency [62], evaluating the midterm patency of stents in nonthrombotic iliac venous lesions [54], and routinely monitoring for iliac vena cava stent obstruction [63].

Fig. 6.

A 59-year-old man with in-stent restenosis.

A. A venogram shows the start and end points of the stent (arrows). Although the venogram appears normal, the distal segment seems narrowed. B. Intravascular ultrasound (IVUS) reveals significant stent compression in the distal segment. The IVUS area measurement is 37 mm² in the common iliac vein (CIV) segment (optimal area is 200 mm²), representing an area reduction of 81%. C. Post-overdilation IVUS imaging shows in-stent restenosis (ISR). D. The in-stent restenosis (ISR) of the external iliac vein (EIV) has been cleared, with improvement in the flow channel. Reproduced from Raju et al. J Vasc Surg Venous Lymphat Disord 2019;7:184-194, according to Creative Commons Attribution License [61].

Current Barriers and Future Directions

Despite extensive data from large-scale randomized controlled trials demonstrating that IVUS enhances the efficacy of percutaneous coronary interventions, there is a scarcity of prospective studies assessing the effectiveness of IVUS in LEVD interventions. The setup and interpretation of IVUS can be challenging for operators who are not familiar with the technique, which may lead to prolonged procedure times and inconsistencies in how image interpretations influence subsequent treatments. There remains a need for standardized treatment protocols, formal training programs, and universal quality metrics. Regarding cost-effectiveness, reimbursement for IVUS differs across countries and might not cover the entire cost of the technology. Looking ahead, innovations such as multimodal IVUS fusion imaging, contrast-enhanced IVUS imaging, and IVUS-guided drug delivery are poised to make their way into clinical practice. Additionally, the development of artificial intelligence models that enhance image interpretation and streamline workflows is anticipated to broaden the application of IVUS, increase its market penetration, and enhance clinical outcomes by enabling quicker, more precise diagnostic and treatment decisions.

Conclusion

IVUS is playing an increasing important role in lower-extremity arterial disease interventions. The evidence supporting the use of adjunctive IVUS in peripheral interventions consistently shows its superiority over conventional angiography. Specifically, IVUS is essential for improving vessel characterization and preparation, ensuring effective stent deployment, characterizing targeted lesions, and monitoring post-procedural complications in selected patient cohorts. Further efforts are necessary to determine how to more effectively integrate the use of IVUS into clinical practice.

Notes

Author Contributions

Conceptualization: Guan X, Han H, Xu H. Data acquisition: Guan X. Data analysis or interpretation: Guan X. Drafting of the manuscript: Guan X. Critical revision of the manuscript: Guan X, Han H, Xu H. Approval of the final version of the manuscript: all authors.

No potential conflict of interest relevant to this article was reported.

Acknowledgements

This work was supported by the Shanghai Municipal Hospital Development Center (Grants SHDC2022CRT016).

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Notes

Key point

Intravascular ultrasound (IVUS) is a diagnostic imaging tool that relies on sound waves to produce precise vessel images and is emerging as a useful adjunct to angiography during peripheral arterial and venous intervention. The utility of peripheral IVUS in clinical settings includes vessel measurement, pre- and post-procedural planning, treatment optimization, and detection of thrombus, dissection, or calcium severity. This review provides an updated overview of the use of IVUS in the management of lower-extremity arterial and venous diseases, offering a valuable reference for clinicians in practice.

Study	No.	Position	Type	Procedure	Objective	Outcome
Saket et al. (2004) [11]	700	Mixed	CTO	PTA/stenting	To report experiences using IVUS to achieve controlled true lumen re-entry in CTO patients undergoing angioplasty	IVUS can improve the technical success rate, reduce the procedure time, and minimize potential complications.
Arthurs et al. (2010) [12]	93	Mixed	Atherosclerosis	IVUS	To compare angiography with IVUS in the same vessels of LEVD	IVUS and angiographic measurements were consistent in luminal diameters and stenosis reduction diameter, and discordant in overall vessel diameter and plaque morphology interpretation.
Kawasaki et al. (2011) [13]	36	Iliac/femoral	Stenosis/occlusion	EVT	To evaluate IVUS-guided EVT in patients with preexisting renal insufficiency	IVUS-guided EVT was feasible and avoided using nephrotoxic contrast media in selected patients.
Hitchner et al. (2015) [14]	59	SFA	Stenosis/occlusion	PTA/stenting	To assess whether IVUS can help with residual disease evaluation and procedure outcome	IVUS provided more accurate intraprocedural insight on residual stenosis extent after SFA interventions.
Kumakura et al. (2015) [15]	455	Iliac	Stenosis	Stenting	To evaluate 15-year patency and life expectancy after IVUS-guided primary stenting	IVUS-guided stenting for the iliac artery had favorable 15-year patency in all TASC categories.
Yin et al. (2017) [16]	47	Mixed	Atherosclerosis	Atherectomy	To validate three angiographic scoring systems for calcification using IVUS as the gold standard	IVUS confirmed that the three calcification scoring systems can be used to classify the extent of calcification, especially superficial calcium.
Kuku et al. (2018) [17]	33	SFA/proximal popliteal artery	Atherosclerosis	Laser catheters	To assess dissections in the vessel wall following the use of laser catheters via IVUS	Turbo-Booster treatment of PAD resulted in plaque debulking and increased lumen diameter with negligible adventitial layer injury.
Aihara et al. (2020) [18]	220	Femoropopliteal	CTO	PTA/stenting	To elucidate the link between lesion features and patency after EVT using IVUS and to determine predictors of restenosis	For stent placement, a large distal plaque burden was related to restenosis.
Aihara et al. (2020) [18]	220	Femoropopliteal	CTO	PTA/stenting		For PTA, a lower calcification angle was related to higher patency.
Shammas et al. (2020) [19]	20	Infrapopliteal	Restenosis	PTA/orbital atherectomy	To investigate whether IVUS yields a more accurate estimate of vessel diameter and dissections after intervention	IVUS measured vessel diameters as 25% larger than angiography and uncovered 3.8 times more dissections.
Allan et al. (2022) [20]	150	Femoropopliteal	Occlusion	EVT	To investigate whether the addition of IVUS guidance reduced the binary restenosis rate within 12 months	The use of IVUS resulted in treatment plan changes in 79% of patients and significantly reduced the restenosis rate after EVT.
Soney et al. (2023) [21]	20	Femoropopliteal	Mixed	PTA/stenting	To assess the reproducibility of IVUS measurements and their association with angiography	IVUS measurements showed strong intra-observer and inter-observer agreement.
Soney et al. (2023) [21]	20	Femoropopliteal	Mixed	PTA/stenting		IVUS and angiography did not show a similar strong agreement.

Study	Study design	No.	Position	Type	Procedure	Objective	Outcome
Neglen and Raju (2002) [49]	Prospective	304	Iliac	Obstruction	PTA/stent	To compare IVUS scanning with venography	IVUS detected fine intraluminal and mural details that were not seen with venography.
Raju and Neglen (2006) [50]	Prospective	319	Iliac	NIVL	Stent	To describe the use of IVUS to diagnose two specific NIVLs	The use of IVUS made it possible to uncover much broader disease profiles.
Murphy et al. (2010) [51]	Prospective	33	Iliofemoral	DVT	Thrombectomy	To determine the most accurate method for assessing clot lysis after percutaneous mechanical thrombectomy	IVUS was superior to venography for the detection of residual thrombus and underlying venous pathology.
Raju et al. (2012) [52]	Retrospective	277	Iliac	Obstruction	Stent	To show that routine IVUS can detect venous obstructions missed by venography	IVUS helped to differentiate primary lymphedema from venous lymphedema.
Gagne et al. (2017) [53]	Prospective	100	Iliofemoral	Obstruction	IVUS	To compare the diagnostic efficacy of IVUS with multiplanar venography for iliofemoral vein obstruction	IVUS was more sensitive than multiplanar.
Gagne et al. (2017) [53]	Prospective	100	Iliofemoral	Obstruction	IVUS		Venography and caused majority plan revisions.
Rizvi et al. (2018) [54]	Retrospective	210	Common/external iliac vein	NIVL	PTA/stenting	To investigate the midterm patency outcome of iliac vein stents placed for NIVLs	IVUS helped to detect the average area of iliac venous segments and the most common locations of the stenoses.
Shammas et al. (2018) [55]	Retrospective	96	Common iliac vein	Compression	IVUS	To evaluate the role of CTA and venography with IVUS in the diagnosis of common iliac vein compression	CTA and not venograms can be used to predict stenosis measured by IVUS.
Montminy et al. (2019) [56]	Retrospective	152	Iliofemoral	Stenosis	Stent	To compare IVUS and angiography in terms of the key parameters for iliac vein stenting	IVUS can detect key parameters that are missed by venography.