More Than a Pretty Image: Envisioning the Use of Coronary Computed Tomography Angiography to Plan Percutaneous Coronary Interventional Procedures

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J INVASIVE CARDIOL 2026. doi:10.25270/jic/26.00193. Epub September 30, 2026.

Since the advent of percutaneous coronary intervention (PCI), there has been a shift to frequent ad hoc procedures following often limited coronary angiography. In addition, flow studies to confirm visual lesion significance and intravascular imaging are recommended for all procedures, as they are associated with improved outcomes¹; however, these techniques are used in a minority of cases both pre and post PCI. As a result, visually significant lesions are often treated with a quick stent, and the procedure is deemed complete based on a visual angiographic assessment, which may not adequately demonstrate appropriate stent/lesion diameter/length and/or deployment, leaving the patient at risk for potential lesion failure later on that could have been prevented by preplanning and optimal stent deployment.

Recently, coronary computed tomography angiography (CCTA) has advanced significantly in its ability to image coronary and lesion details, providing excellent coronary anatomy with less calcium and prior stent distortion. This has led to greater diagnostic use, limiting the need for separate coronary angiography. Furthermore, CCTA can provide important imaging information for planning a PCI procedure, such as the optimal equipment and devices needed as well as an optimal coronary imaging view to minimize multiple coronary angiograms. The evolution of these features through the work of different vendors has led to the concept of using CCTA to preplan a PCI. While previously reported, this concept gained increased recognition following the first randomized trial that reported favorable results in patients undergoing chronic total occlusion PCI.²

In the October 2026 issue of the Journal of Invasive Cardiology, Carvalho et al³ report the results of a think tank described as the first US-based CCTA-guided PCI Summit. Participants included interventional cardiologists, CT imagers, and multiple other groups, including industry and, likely, engineers. The purpose of the Summit was to discuss the potential technical advancements as well as limitations of this technology, and how this specialized use of CCTA can be enhanced and made more widely available, while recognizing that further testing and studies are warranted to confirm value.

I congratulate the leaders of this event for their forward thinking and for the incorporation of industry in the early planning. The combination of industry professionals, who are concerned about proprietary considerations, and physicians, who are concerned about marketing complicating science, often limits such work groups. Thus, the Summit appears to be a real win by utilizing the best of both groups and (hopefully) appealing to engineers, as engineers can produce remarkable innovation, but must also understand the needs and existing limits of the technology at hand to be most effective in accelerating its advancement.

A number of the authors’ considerations appear to be particularly valuable. Noteworthy is the assurance that CCTA has the capability of providing the best view (or views) to assess the target lesion. This can potentially limit radiation exposure and contrast use by eliminating the need for multiple angiographic test views to find the optimal view for lesion assessment during PCI. Likewise, CCTA’s ability to assess lesions for calcium; determine the type and stability of the plaque, including length; and identify focal vs diffuse disease is helpful. Preplanning can also allow more team decisions as to whether medical therapy, PCI, or cardiac surgery is best suited for the case at hand. Analysis of CCTA fractional flow reserve could even help the team determine whether intervention is necessary. For PCI, preplanning can predict the optimal equipment choice, potentially limiting the number of discarded catheters, wires, and devices, which without preplanning but through operator trial and error can lead to wasted equipment and longer procedure times, all associated with excess cost.

Though not mentioned by the authors, another conceivable opportunity could be the use of CCTA lesion characteristics to provide predictive models relative to the optimal type and duration of post-PCI antiplatelet agents in order to optimally protect against lesion failure with the lowest risk of bleeding. All of the above-mentioned applications are potential opportunities for better, more efficient procedures that could lead to cost savings and lower contrast use.

Despite these opportunities, there are challenges. The contrast and radiation benefits noted above are dependent on the effectiveness of the preplanning in achieving the proposed benefit. Furthermore, adding a CCTA to many/most PCI procedures could add a cumulative radiation risk for patients if the procedure fails to significantly reduce radiation use. In addition, the preplanning could improve late results based on better treatment approaches, but this may require not only preplanning but post-procedure assessment. Detailed post-PCI assessment would require intravascular ultrasound which, as noted above, is currently infrequently used, but if deployed would potentially increase the cost associated with the CCTA. However, recent studies⁴ have failed to demonstrate the value of intravascular assessment, at least by high-volume interventionalists, so this may become less of a consideration except in special cases.

Lastly, one of the more challenging aspects of the CCTA-PCI preplanning technology is the ability to make the technology available across the full spectrum of hospitals, interventionalists, and imagers. Specialized imaging is expensive, and the expertise to optimally provide the necessary imaging will be challenging in smaller settings. In large institutions, it is likely that specialized imagers will be dedicated primarily to the technology, while in smaller hospitals imagers will frequently be covering multiple modalities. Some of this will be overcome by autonomous artificial intelligence (AI)-enhanced technology automatically providing the expected interpretations. Likewise, interventional cardiologists will need to be educated on how to apply and utilize the information provided by the CCTA imaging process in order to take optimal advantage of the findings; this education will be critical to the successful utilization of the technology.

In summary, the concept and early results are very encouraging and, given the current rapid evolution of AI and technology, one can expect even greater advancements in rapid succession. Important to the value and applicability will be additional randomized trials with additional results from more general-use registries. These must focus on value in terms of acute and long-term patient outcomes, and cost as well as safety, particularly regarding the total radiation levels for patients.

As efficacy is presumably demonstrated, increasing the applicability to lower-volume hospitals and operators will require special strategies. For example, centralized analyses of locally derived CCTAs could significantly reduce capital outlay but does not completely resolve the cost and education components.

Congratulations to the PCI Summit leaders for assembling an excellent, diverse group of participants to help pave the way for the development of the technology by evaluating current capabilities, future development needs, limitations, and challenges.

George W. Vetrovec, MD, MACC, MSCAI

Professor Emeritus, Virginia Commonwealth University, Richmond, Virginia.

Disclosures: The author reports no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: George W. Vetrovec, MD, MACC, MSCAI, Professor Emeritus, Virginia Commonwealth University, 3126 W. Cary St. #693, Richmond, VA 23221, USA. Email: gvetrovec@gmail.com