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As someone who has never had an opportunity to play with it, I’m fascinated by what people are doing with PIO. In many cases it seems to be a ‘good enough’ FPGA on absurdly cheap hardware.
Honestly what they're describing can be done on any MCU without PIO - set up clock division/PLL to provide ADC clock, use that same clock for timer source, set up a timer channel to trigger the pulse, set up a timer channel to trigger ADC DMA capture start, start the timer.

Congrats, now you have capture synchronized to pulse start "providing the sub-microsecond timing needed for ultrasound acquisition".

What are the practical applications of this? The things that come to mind when I hear "ultrasound" are medical devices and wall scanners.

That said, it's a cool project, even if it doesn't have a practical use.