Intravascular ultrasound–guided versus angiography-guided endovascular interventions for peripheral artery disease: a systematic review and meta-analysis

Background Endovascular revascularization is a cornerstone therapy for peripheral artery disease (PAD), typically guided by angiography, which may underestimate vessel size and lesion complexity. The clinical benefit of intravascular ultrasound (IVUS) guidance remains uncertain. This systemic review and meta-analysis compare clinical outcomes of IVUS-guided versus angiography-guided endovascular interventions in patients with PAD. Methods PubMed/MEDLINE, Cochrane, Scopus, Web of Science, EMBASE, and Google Scholar were searched from inception through January 30, 2026, for randomized and observational studies of adults with PAD undergoing endovascular interventions with IVUS versus angiography. Primary outcomes were primary patency, target lesion revascularization (TLR), and late lumen loss. Secondary outcomes included major adverse limb events, amputation, procedural success, and ankle–brachial index improvement. Random-effects meta-analysis was performed using R version 3.4.3. Results Twenty-three studies encompassing 1,232,018 patients were included. There was no significant difference between IVUS-guided and angiography-guided interventions (RR 1.03; 95% CI 0.81–1.23; p = 0.75; i2 = 60.3%) or freedom from TLR (RR 1.21; 95% CI 0.96–1.54; p = 0.08; I2 = 58.6%). Conclusion IVUS-guided endovascular interventions in PAD were associated with reduced all-cause mortality, but similar limb-related outcomes compared with angiography guidance. However, these findings are based predominantly on observational evidence. Large-scale randomized trials are needed to confirm these findings and identify patient subgroups that would benefit from IVUS-guided strategies.