Clinical applications of contrast-enhanced ultrasound in vascular surgery: State-of-the-art narrative and pictorial review

<h2>ABSTRACT</h2><h3>Introduction</h3> Contrast-Enhanced Ultrasonography (CEUS) has emerged as a powerful, non-invasive imaging modality in vascular surgery. By using microbubble contrast agents, CEUS enhances vascular imaging, allowing for real-time, high-resolution visualization of blood flow and microvascular perfusion. Unlike other imaging techniques such as computed tomography angiography (CTA) and magnetic resonance imaging (MRI), CEUS does not require ionizing radiation or nephrotoxic contrast agents, making it a safer option for patients with renal impairment. <h3>Methods</h3> This narrative review examines the state-of-the-art applications of CEUS in vascular surgery. A comprehensive literature search was conducted in PubMed, MEDLINE, Embase, Ovid, and Scopus for articles published between 2000 and 2024. Studies addressing CEUS applications in carotid artery disease, aortic aneurysms, peripheral arterial disease, and venous disorders were analyzed. <h3>Results</h3> CEUS has demonstrated significant advantages in multiple vascular conditions. In carotid artery disease, CEUS enhances the detection of vulnerable plaques, improving risk stratification for cerebrovascular events. In aortic aneurysms, CEUS aids in assessing aneurysm wall integrity, endoleak detection post-endovascular repair, and monitoring growth rate. For peripheral arterial disease, CEUS provides insights into skeletal muscle microperfusion, aiding in disease severity stratification. In venous disorders, CEUS improves the visualization of deep vein thrombosis and incompetent perforator veins, optimizing diagnosis and treatment planning. Additionally, emerging applications of CEUS include artificial intelligence-assisted imaging and sonothrombolysis, which utilizes microbubbles for targeted thrombus dissolution. <h3>Conclusions</h3> CEUS represents a valuable imaging tool in vascular surgery, offering superior diagnostic accuracy while minimizing patient risk. Despite its advantages, CEUS remains underutilized in clinical practice, likely due to operator dependency and limited standardization. Future research should focus on optimizing CEUS protocols, integrating artificial intelligence for automated analysis, and expanding its role in therapeutic applications. Increased awareness and training may further establish CEUS as a routine vascular imaging modality.