The role of IVUS in BEVAR as additional intraoperative tool: procedure guidance and quality control imaging

Background: Intravascular ultrasound (IVUS) is a catheter-based imaging technique that utilizes high-frequency sound waves to produce real-time, cross-sectional images of the vessel lumen. IVUS is a well-known endovascular imaging tool for peripheral and aortic procedures, with potential benefit also during branched endovascular aortic repair (BEVAR) Methods: We conducted a single-center retrospective observational study, including 47 patients undergoing elective BEVAR procedure from 2020 to 2024. Exclusion criteria were acute dissection, frank rupture. Two groups were compared: an IVUS-guided group, with routine IVUS for BEVAR procedure guidance, as intraoperative tool for post - implant bridging stent quality control; a NON-IVUS-guided group underwent standard BEVAR procedures without IVUS use. Primary endpoints are technical success of IVUS assessment for each target vessel, incidence of intraoperative branch instability detected by IVUS, and absence of IVUS-related adverse events. Secondary endpoints are procedural metrics, rate of intraoperative revisions prompted by IVUS findings, and postoperative outcomes such as branch instability requiring reintervention, as confirmed by follow-up imaging. Results: There were 27 BEVAR (nine type I-III, 11 type IV, seven post-dissection TAAAs) in IVUS group and 20 (seven type I-III, eight type IV, five post-dissection TAAAs) in NON-IVUS group. Overall, there were no differences in operative time (median procedure time 310 vs. 318 min; P=0.89) and Xray exposure (47.3 vs. 47.5 mGy, P=0.99) between the two groups. There was a significant reduction of contrast volume for the main graft deployment phase (P=0.021) and X-ray reduction during the bridging stent phase (P=0.012); 76 TVVs were treated in group NON-IVUS group and over 103 bridged target vessels in IVUS group, the number of branch instability as kinking or compression identified with IVUS and not with angiography was 22%; this required additional unplanned reinforcement with stent reinforcement in 16% of the cases. Conclusions: This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability and highly sensitive in the identification of morphological defects, reducing Xray exposure or contrast volume for selected steps of the procedure. Long term investigations on larger cohorts are required to validate these promising results.