Coronary CT Angiography for PCI Planning and Guidance: A Comprehensive Narrative Review

Area of Science:

• Cardiovascular Imaging
• Interventional Cardiology
• Medical Technology

Background:

• Coronary computed tomography angiography (CCTA) is evolving as a key tool for planning percutaneous coronary intervention (PCI).
• Integrating plaque morphology, calcium burden, and CT-derived physiology allows for non-invasive assessment of lesion complexity.
• Precision-guided revascularization strategies are increasingly supported by CCTA data.

Purpose of the Study:

• To synthesize current evidence on CT-guided PCI, reviewing original studies, registries, and guidelines.
• To evaluate the role of CCTA in assessing various lesion types, including bifurcations, ostial lesions, and chronic total occlusions (CTOs).
• To explore emerging technologies and their impact on CT-guided PCI.

Main Methods:

• Narrative review of literature identified through PubMed, Embase, and Google Scholar.
• Focus on CCTA-based plaque characterization, calcium assessment, FFR-CT, virtual PCI simulation, and fusion imaging.
• Inclusion of contemporary trials like SYNTAX III, P3, and the P4 trial.

Main Results:

• CCTA accurately characterizes stenosis severity, plaque distribution, and calcification, showing strong concordance with intravascular imaging.
• CT-based measurements aid in stent sizing, predicting calcium modification needs, and identifying high-risk features in complex lesions.
• CCTA improves CTO assessment and virtual PCI planning, predicting post-PCI hemodynamics.

Conclusions:

• CCTA is a reliable tool for comprehensive PCI planning, offering detailed insights into lesion complexity.
• Emerging technologies like photon-counting CT and AI-assisted analysis further enhance CCTA's role in CT-guided PCI.
• The P4 trial is anticipated to provide definitive validation, potentially leading to routine clinical adoption of CT-guided PCI.