To evaluate the clinical utility of Intravascular Ultrasound (IVUS) in carotid artery interventions (Carotid Artery Stenting) and develop a future consensus for research and practice parameters.

A systematic review and meta-analysis was performed of the English literature articles published till February-2021. Studies reporting on IVUS parameters and findings and also its performance compared to other imaging modalities were included in review. Pooled prevalence with 95%Confidence-Intervals was calculated. The statistical analysis was conducted in R version-3.6.2. This review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PROSPERO International Prospective Register of Systematic Reviews registration number is CRD42021223079.

A total of 2015 patients from 29 studies were included. Proportional meta-analysis was performed on 1566 patients from 11 studies. In nine studies, stroke/TIA (Transient Ischemic Attack) had a pooled prevalence of 4% (95%,CI 3-5%) while asymptomatic stroke had a pooled prevalence of 46% (95%CI,31-62%) in four studies following IVUS. Two studies reported that IVUS detected more plaque protrusion compared to angiography (n= 33/396 vs. 11/396). IVUS led to stent type or size change in 8 of 48 cases which were missed on angiography in three other studies. Concordance between VH-IVUS and true histology was good at 80-85% reported in two studies. 

This systematic review and meta-analysis showed though IVUS fared better to CT/MR angiography for better stent selection during CAS, with low to moderate risk of bias in the studies included. However large scale, preferably randomized controlled studies are needed to predict its role in determining clinical outcome.