Fujian's First Case: IVUS-Guided Complex Lower Extremity Artery Endovascular Treatment by Prof. Zhuang Hui's Team at Xiamen University Affiliated Cardiovascular Hospital

An 82-year-old woman walked barely 20 meters before her right calf seized with pain. Six months earlier, she could manage 100 meters. Now the shrinkage of her pain-free stride told a grim story: her arteries were shutting down.

At Xiamen University Affiliated Cardiovascular Hospital, a team led by Professor Zhuang Hui saw the imaging and faced a formidable challenge. Computed tomography angiography revealed diffuse atherosclerotic disease across her abdominal aorta and both lower limbs. On the right side, the common iliac artery was critically narrowed. The superficial femoral artery was riddled with multi-segment stenosis. From the distal SFA through the popliteal artery, the vessel was completely occluded. Below the knee, the anterior tibial, posterior tibial, and dorsalis pedis arteries barely showed on imaging. The runoff was poor.

The diagnosis was lower extremity arteriosclerosis obliterans with gangrene — compounded by hypertension, hyperlipidemia, hypercholesterolemia, coronary artery disease, and prior gallbladder removal. This was not a single-blockage problem. It was a full-spectrum vascular failure.

Going Beyond 2D Angiography

Digital subtraction angiography confirmed what the CTA suggested: a short-segment stenosis in the right common iliac artery with flow limitation; a "worm-eaten" pattern throughout the right SFA; no antegrade flow beyond the distal SFA into the popliteal segment; and delayed collateral compensation through the peroneal artery, which alone kept the foot arch perfused.

Two-dimensional angiography can show where blood does and does not go. It cannot show what the vessel wall looks like. For that, the team turned to intravascular ultrasound — specifically, the TrueVision 18® peripheral IVUS system developed by InSight Lifetech (Shenzhen-based Insight Lifetech Co., Ltd.), a next-generation domestic platform operating at 30 MHz, the highest imaging frequency among peripheral IVUS systems developed in China.

After recanalizing the femoropopliteal segment with a Command ES guidewire and a Boston Scientific Coyote 3.0×220 mm PTA balloon, the team advanced the TrueVision 18® catheter into the diseased territory. What it revealed went well beyond what fluoroscopy could show.

The Numbers Behind the Disease

InSight Lifetech's inSmartVision™ intelligent analysis platform generated precise cross-sectional measurements across the treated segments:

• Distal popliteal reference segment: mean vessel diameter 4.57 mm, mean lumen diameter 3.18 mm, plaque burden 51%.

• Superficial femoral artery reference segment: mean vessel diameter 7.40 mm, mean lumen diameter 4.79 mm, plaque burden 56%.

• Worst segment: minimum lumen area just 2.84 mm², mean lumen diameter approximately 1.90 mm, plaque burden reaching 93%.

The IVUS also characterized the plaque: predominantly eccentric mixed-echo lesions with scattered calcification. In places, the plaque surface showed continuity disruption with fissures communicating with the lumen — a double-lumen pattern consistent with plaque tear and intimal dissection or a subintimal channel. The overall picture was one of long-segment, multi-level severe stenosis across the femoropopliteal artery.

Drug-Coated Balloons, Then a Stent

With the lesion characterized, the team moved to treat. An Acenova drug-eluting peripheral balloon (4.0×150 mm) was deployed first, followed by two Boston Scientific Ranger paclitaxel-coated balloons — 5.0×200 mm and 6.0×150 mm — in sequential dilation across the tibial-peroneal trunk, popliteal artery, SFA, and CFA. Post-dilation angiography showed restored flow.

A second IVUS pullback confirmed the result: the stenotic segments had expanded significantly. Residual eccentric plaques and focal calcification remained, and some segments showed irregular lumen morphology — expected after balloon angioplasty of heavily diseased vessels. A minor intimal dissection was visible, but there was no flow-limiting flap, no intramural hematoma, and no free thrombus.

Angiography then confirmed a residual stenosis in the right common iliac artery. The team deployed two Bard E-Luminexx bare metal stents, each 10×60 mm, to cover the iliac lesion. Final IVUS of the stented iliac segment showed good expansion and wall apposition. The narrowest point in the stent measured approximately 4.69 mm in diameter. No severe edge dissection, malapposition, or thrombus was detected.

Post-procedure angiography confirmed patent flow throughout the previously occluded right lower limb, with good distal perfusion.

A Closed Imaging Loop

The case underscored what interventionalists have long argued: angiography alone is a roadmap, but IVUS is the terrain. In this procedure, IVUS performed three distinct roles. First, it characterized plaque morphology and calcification distribution that 2D imaging could not resolve. Second, it provided quantitative reference diameters and plaque-burden data across multiple segments, enabling device selection and segment-by-segment treatment planning. Third, it served as an immediate post-treatment verification tool — confirming lumen gain, residual stenosis, dissection status, and stent apposition in real time.

The result was what the team described as a complete imaging loop: precise assessment → strategy support → outcome verification.

The Device Behind the Data

The TrueVision 18® system is InSight Lifetech's flagship peripheral IVUS platform. Operating at 30 MHz, it offers the highest ultrasound imaging resolution among domestically developed peripheral IVUS products. Its imaging diameter covers most peripheral vessels — carotid, femoral, and popliteal arteries among them. The integrated inSmartVision™ platform provides automated vessel and lumen segmentation, while EasyGo angiography registration technology overlays IVUS data onto fluoroscopic images for real-time spatial correlation.

For Professor Zhuang Hui's team, the technology represented more than a first-in-province milestone. It represented a shift from seeing the vessel as a silhouette to seeing it as a structure — wall, plaque, lumen, and all.

The 82-year-old patient, whose calf pain had shrunk her world to 20-meter increments, walked again. This time, her surgeons could see exactly why.