IVUS Use During Peripheral Arterial Intervention Lowers Risk of Major Adverse Limb Events

Use of IVUS is associated with improved limb outcomes when included as part of the peripheral arterial intervention procedure.

Intravascular ultrasound (IVUS) use during lower extremity peripheral arterial intervention is associated with a lower risk of short- and long-term major adverse limb events, according to study findings published in the Journal of the American College of Cardiology: Cardiovascular Interventions.

Investigators sought to study practice variation, temporal trends, and associated outcomes with the use of IVUS during peripheral arterial intervention. The primary outcome was major adverse limb events, defined as a composite of acute limb ischemia or major lower extremity amputation.

The investigators conducted an observational analysis of all Medicare beneficiaries greater than 65 years of age who underwent peripheral arterial interventions from 2016 through 2019 patients (N=479,756) and used IVUS (n=63,372). Temporal trends in IVUS were stratified based on physician specialty and whether the procedure was done in an inpatient, outpatient, or ambulatory surgery center/office-based laboratory settings.

Use of IVUS during peripheral arterial intervention was greater in ambulatory surgery center/office-based laboratory settings (26.8%) compared with outpatient (5.2%) or inpatient (4.0%) settings, and was performed by interventional radiologists (17.4%), surgeons (11.5%), cardiologists (10.3%), or other physician specialties (10.4%).

IVUS use during PVI has increased since 2016, driven by growth in the ASC/OBL setting.

The investigators found significant growth in IVUS use in the ambulatory surgery center/office-based laboratory setting (2016 to 2019 growth, 23.6%) and noted significant variation in use. Among the 12,844 operators included in the study, the mean use of IVUS during peripheral arterial intervention was 6.5% (median, 0.0%; IQR, 0%-5%). Among operators who used IVUS at least once during the study period (N=3822), mean use was 13.4% (median 5.4%; IQR 2.2%-15.0%).

The investigators observed that use of IVUS during peripheral arterial intervention was associated with a 28% reduction in the hazard ratio (HR) for developing major adverse limb events through a median of 514 days (adjusted HR, 0.73; 95% CI, 0.70-0.75; P <.0001). Similar reductions were found in the composite outcomes, acute limb ischemia (adjusted HR, 0.82; 95% CI, 0.78-0.87; P <.0001) and major amputation (adjusted HR, 0.69; 95% CI, 0.66-0.71); P <.0001). Similar findings were noted with stratification by severity of peripheral artery disease, and by anatomic location of peripheral arterial intervention.

Analysis limitations include ambiguity of claim codes, claim codes that do not explain how IVUS was incorporated into procedures resulting in possible misclassification, observational study design, lack of detailed procedural and clinical information, exclusion of patients who underwent unsuccessful endovascular revascularization, and the possibility of residual and unmeasured confounding.

Investigators concluded “IVUS use during PVI [peripheral arterial intervention] has increased since 2016, driven by growth in the ASC/OBL [ambulatory surgery center/office-based laboratory] setting.” They reiterated the substantial variation in operator practice and added “When used during PVI [peripheral arterial intervention], IVUS was associated with a lower risk of short- and long-term MALE [major adverse limb events].”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Divakaran S, Parikh SA, Hawkins BM, et al. Temporal trends, practice variation, and associated outcomes with IVUS use during peripheral arterial intervention. JACC Cardiovasc Interv. Published online October 24, 2022;15(20):2080-2090. doi:10.1016/j.jcin.2022.07.050