One in five people with critical limb-threatening ischemia loses the limb within twelve months. One in five dies in the same window. We have accepted those numbers for a long time, and a lot of brilliant work has gone into pushing them down — better wires, better balloons, better adjuncts, smarter procedural algorithms. But there is one part of the peripheral arterial disease workflow that has not kept up with the rest of the field, and it is the imaging.

In peripheral vascular, the missing piece is intravascular imaging that actually matches the anatomy and the workflow operators are working in.

We Brought A Flashlight to a Wall Problem

Here is what I mean. We treat the legs from a lumenogram — angiography on the table, ankle-brachial index in the clinic. Both measure the consequence of the disease. Neither shows the wall. Plaque morphology, calcium pattern, lipid burden, dissection extent — none of that lives in the column of contrast on the screen. It lives in the vessel wall, and the wall is where the intervention strategy actually gets decided.

This is not a vendor opinion. In January 2024, six interventional societies — SCAI, SVS, SIR, AVF, AVLS, and SVM — co-signed a multidisciplinary expert consensus in the Journal of the Society for Cardiovascular Angiography & Interventions, led by Dr. Eric Secemsky at Beth Israel Deaconess. The committee was direct: angiography is limited in its ability to accurately size vessels, characterize lesion morphology, or diagnose post-intervention complications. The field has acknowledged the gap. Closing it has been the harder problem.

Cardiologists figured this out a decade ago. Intravascular ultrasound. Optical coherence tomography. Multi-modality intracoronary imaging is now table stakes in any complex PCI lab. The peripheral lab has been waiting for the same toolset, scaled to vessels that are sometimes a third the diameter of the LAD, in a workflow that runs from the iliacs all the way down to the pedal arch.

The arrival of intravascular lithotripsy made that imaging gap impossible to ignore. Once you have a tool that can fracture calcium without barotrauma, the question changes. It stops being how hard do I push the balloon and starts being where exactly is the calcium, and what shape is it in. The intervention got smarter. The imaging did not keep up.

What the Lab Actually Needs

Talk to peripheral operators long enough and the brief comes through clearly. The imaging has to do three things at once.

It has to look forward. Half the work below the knee is crossing a lesion you cannot see past. Side-fire rotational ultrasound shows you what is already behind you. That is the wrong direction.

It has to fit. The pedal arch is roughly a millimeter wide. A catheter built for the iliac is a brick in a tibial. The form factor has to match the anatomy, not the other way around.

And it has to see the wall, not just the lumen. In routine cases, a clean forward view of plaque and calcium pattern is enough to plan and confirm the work. In the harder cases — long below-the-knee disease, post-lithotripsy assessment, dissections you have to find before they become problems — operators want more than one imaging modality on the same catheter. The clinical truth lives in the overlap.

The imaging that wins the leg has to be small enough for the pedal, forward-looking enough to cross a lesion, and smart enough to see the wall — not just the lumen. That’s the brief. Anything less is a half-measure.

Built For the Brief

What I can tell you, as the commercial lead at VerAvanti, is that this is the brief we have been building against. And the way we have been building it reflects something the field is finally saying out loud: two things are needed at once, not one.

The urgent need is basic forward-view, sub-millimeter visualization. Peripheral operators do not have it today. The day they do, the routine work gets immediately better — calcium pattern is read accurately, the wire is placed where it needs to be, the post-intervention call is made with confidence rather than hope. This is not a luxury feature. It is the basic peripheral imaging layer the field has been waiting on for a decade.

The elevation is optical coherence tomography on the same platform. OCT is what carries the harder cases — long below-the-knee disease, post-lithotripsy assessment, dissection detection — into a higher class of imaging entirely. It is the difference between knowing where the lesion is and knowing what the lesion is. Adding OCT to a forward-view platform does not just add a feature. It moves the platform up an entire tier.

We have been building both. One architecture, two tiers — the urgent baseline the field needs, and the elevated capability that meets the hardest peripheral cases on their own terms. Built to match the case rather than force the case to match the tool.

I will not make performance claims here. The work is investigational, and I am a commercial operator, not a regulator. What I can say is that the platform is real, the first-in-human work is in motion, and the day this kind of imaging reaches peripheral interventionalists in the cath lab is closer than the field knows.

The principal investigator for that first-in-human study is Dr. Patrick McVeigh, of the Division of Vascular Surgery at the University of Toronto. Patrick produced the first in-vivo intravascular images on this platform during his PhD years in medical biophysics. There is no peripheral vascular surgeon in the world with deeper technical fluency on the imaging architecture, and his leadership is the reason I am confident the brief gets met — not because of any single specification, but because the clinical translation is being led by an operator who has lived inside the imaging physics for years.

The Leg Has to Come Home With the Patient

Peripheral arterial disease affects more than 200 million adults worldwide. Annual peripheral interventional volume runs over a million procedures in the United States alone.

Every one of those cases is a planning decision and a confirmation decision, and most of them are still being made on a lumenogram. That is not an academic concern. It is the reason we still see the amputation rates we see in critical limb-threatening ischemia. Imaging that lags the intervention by a decade is not a minor inconvenience — it is the difference between a foot that heals and a foot that comes off.

When the imaging finally matches the intervention, the call gets easier. The lesion is mapped. The lithotripsy is placed where the calcium actually is. A dissection, if it happens, is found before it becomes a problem. The leg goes home with the patient.

That’s the gap we are working against. Closing it is what we are here to do.

Reference

Secemsky EA, Aronow HD, Kwolek CJ, et al. Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS. Journal of the Society for Cardiovascular Angiography & Interventions (JSCAI). January 9, 2024. Published simultaneously in the Journal of Vascular and Interventional Radiology and the Journal of Vascular Surgery — Vascular Insights.