Coronary Computed Tomography Angiography to Guide Percutaneous Coronary Intervention: Proceedings From the 1st CCTA-Guided PCI Summit in the United States

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J INVASIVE CARDIOL 2026. doi:10.25270/jic/26.00085. Epub June 23, 2026.

Coronary computed tomography angiography (CCTA) can be used beyond diagnostic purposes to support the preprocedural planning of percutaneous coronary intervention (PCI). Advances in scanner technology, software platforms, and physiology- and plaque-based visualization tools have expanded the role of CCTA-guided PCI. CCTA provides detailed assessment of coronary anatomy, plaque and calcium morphology, lesion length, vessel size, and noninvasive physiology, offering opportunities to anticipate procedural complexity, optimize resource utilization, and individualize PCI strategy. Emerging data, including randomized studies in chronic total occlusions and ongoing multicenter trials, support the feasibility and potential clinical value of this approach. In April 2024, the first CCTA-guided PCI summit in the United States convened interventional cardiologists and cardiac imagers, as well as industry stakeholders, to discuss the evidence, technical considerations, clinical applications, and unmet needs related to CCTA-guided PCI. This manuscript summarizes the key discussions and conclusions specific to this meeting, with a focus on the transition of CCTA from a diagnostic to a therapeutic planning tool, emerging artificial intelligence applications, its complementary role with intravascular imaging, and opportunities to enhance procedural planning and decision-making. While early experience is promising, broader adoption will require broader educational efforts, access to purpose-built visualization software tools designed for interventional cardiologists, multidisciplinary collaboration, and additional randomized and real-world studies to define its impact on clinical outcomes and procedural efficiency.

Coronary computed tomography angiography (CCTA) is increasingly used to guide percutaneous coronary intervention (PCI). It can be used for preprocedural planning, as well as for intraprocedural guidance with C-arm and CCTA co-registration. The emerging opportunities with CCTA-guided PCI are enabled by several converging factors, including improvements in scanner technology, the development of scalable software solutions, the use of artificial intelligence (AI), greater technical expertise in image acquisition and interpretation, multidisciplinary collaboration, and increased availability and ease of access to CCTA. Additional drivers include the translation of lessons learned from transcatheter structural interventions and the heart-team approach, the increasing use of CCTA in patients with suspected or established acute or chronic coronary syndromes, and growing evidence supporting its use for PCI guidance.

In patients undergoing PCI, intravascular imaging (IVI) and invasive coronary physiology are guideline-recommended tools to inform procedural decision-making based on the assessment of lesion morphology, including plaque characterization and calcium assessment, lesion length, proximal and distal reference vessel diameters, and functional significance. While similar information can be obtained noninvasively from CCTA for preprocedural planning, such data have traditionally not been used in the cardiac catheterization laboratory by interventional cardiologists (IC). This is in part due to limited training and familiarity with the use and interpretation of CCTA, limited access to purpose-built software applications designed for ICs, a paucity of supporting data and lack of established workflows, and limited collaboration with cardiac imagers and radiologists.

In recent years, there have been multiple technical innovations and a growing evidence base to support CCTA-guided PCI. Randomized data support its use to improve PCI success in patients with chronic total occlusions (CTO). There is also an ongoing pivotal P4 (Precise Procedural and PCI Plan) randomized clinical trial evaluating CCTA-guided PCI; it compares a structured preprocedural CCTA planning package and intraprocedural guidance with C-arm co-registration with intravascular ultrasound (IVUS), with 1-year major adverse cardiovascular events (MACE) as the primary endpoint, further accelerating interest in this space. While educational efforts have taken place in Europe, there is limited awareness and understanding about the potential opportunities with CCTA in the United States.

To educate and discuss opportunities with CCTA-guided PCI, we organized the first US-based CCTA-guided PCI summit.

During a 1.5-day meeting held from April 4 to 5, 2024, in Minneapolis, Minnesota, stakeholders from academia, ICs, and cardiac imagers (including noninvasive cardiologists and radiologists), as well as industry, considered the challenges and opportunities of CCTA-guided PCI. This meeting was organized by Drs Yader Sandoval, João L. Cavalcante, and Emmanouil S. Brilakis through the Center for Coronary Artery Disease at the Minneapolis Heart Institute Foundation (MHIF) in partnership with the Allina Health Minneapolis Heart Institute. The meeting included 76 participants, primarily from from the United States, along with key opinion leaders from Europe and Canada. Physicians with expertise in interventional cardiology, including coronary physiology, IVI, complex coronary interventions, and/or CCTA imaging were recruited through direct invitation by the meeting organizers.

The meeting format consisted of alternating sessions of brief moderated presentations following a formal agenda and faculty-led discussions. Additionally, the meeting included hands-on training sessions, and live CCTA-guided PCI cases (Figure 1). Detailed notes were recorded during the meeting describing the presentations and discussion. The statements in this manuscript were not derived through a voting process; rather, the manuscript was circulated among the faculty, who reviewed and refined the key messages from this scientific summit. Presenters shared their slide sets for reference during the manuscript development. This paper summarizes the discussion and conclusions of this meeting.

1. CCTA: The transition from a diagnostic to an interventional planning tool

The utilization of CCTA has seen a significant rise in recent years owing to its diagnostic accuracy in identifying coronary artery disease (CAD).^1-5 CCTA offers advantages over invasive coronary angiography (ICA), including a noninvasive approach, 3-dimensional anatomy analysis, lower cost, and higher diagnostic accuracy.^6,7 Additionally, it allows a detailed assessment of lesion location, plaque composition, calcium burden, lesion length, physiology assessment, and integration with newly developed AI tools.⁸ Currently, CCTA holds a level 1A recommendation in the management of patients presenting with chest pain and suspected CAD.⁹

Moving beyond diagnosis, in patients suitable for PCI, CCTA can provide a comprehensive anatomical and physiological assessment that can aid in preprocedural planning. It enables the optimization of resources based on case complexity and can inform case triage to the appropriate setting (hospital with on-site surgery, hospital without surgery on-site, or ambulatory surgical center), operator, and scheduling. Randomized trials in selected populations, such as patients with CTOs and those with prior coronary artery bypass grafting (CABG), have demonstrated improved procedural efficiency with CCTA-guided PCI.^10,11 While evidence from the pivotal P4 trial evaluating CT-guided PCI in patients with stable CAD or stable non-ST-elevation acute coronary syndrome with significant lesions (>70% diameter stenosis and fractional flow reserve [FFR] derived from CCTA [FFR_CT] <0.80, including CTOs) is pending, CCTA-guided PCI can facilitate preprocedural planning, anticipate case complexity, and inform equipment selection—including access sheath size, guide catheter and guidewires(s) selection—risk assessment, and calcium modification strategies, which may shorten fluoroscopy time and reduce contrast use during PCI.⁸

2. CCTA to analyze lesion morphology, including plaque characterization and calcium assessment, lesion length, and vessel diameter

IVI, utilizing either IVUS or optical coherence tomography (OCT), is used to characterize plaque burden, lesion morphology, and guide stent size and expansion.¹² Its use significantly reduces the risk of adverse cardiovascular events such as myocardial infarction (MI), cardiac death, stent thrombosis, and target lesion revascularization.¹³ Despite the evidence, widespread availability of IVI remains limited, with utilization in less than 10% to 15% of PCIs in the United States.¹⁴ Concerns about procedural time, reimbursement, and operator dependence may contribute to its underuse.^14-16

CCTA provides preprocedural insights about vessel course and tortuosity, coronary ostium position, and ideal fluoroscopic angles for PCI.⁸ At the first US CCTA‑guided PCI summit, participants and faculty reviewed how standard post‑processing tools can support procedural planning, including the use of maximal intensity projection (MIP) for case overview, disease complexity, and optimal fluoroscopic angles; axial views to define coronary ostium position and guide selection; and multiplanar reformations (MPR) with short‑axis cross‑sections to identify landing zones and inform stent length. The group also discussed emerging AI‑enhanced platforms for plaque and calcium characterization, as well as the integration of FFR_CT to establish functional significance, define the disease phenotype, and perform virtual PCI with predicted post‑PCI FFR_CT values (Figure 2).

Analogous to IVI, CCTA offers adequate assessments of plaque and calcium morphology, as well as lesion length, to inform PCI planning. While traditional energy-integrated CCTA overestimates calcium volume, correlation studies with OCT indicate that calcium arc and length can be assessed adequately with CCTA and potentially inform the need for calcium modification strategies.¹⁷ There is also interest in emerging concepts, such as exploring the use of calcium density, to facilitate such decisions and increase opportunities to help delineate the use of calcium modification tools, such as atherectomy or intravascular lithotripsy.¹⁸  Rather than competing, CCTA complements IVI. While CCTA is valuable for preprocedural planning and can facilitate intraprocedural guidance based on CCTA and C-arm co-registration, it does not allow assessment of postprocedural stent optimization outcomes such as confirmation of adequate stent expansion and apposition or detection of stent edge dissections. Thus, while CCTA facilitates PCI planning and enhances procedural preparedness, it remains a complementary modality to IVI.

Opportunities remain to standardize vessel diameter assessment using CCTA. With IVI, when visible, the external elastic lamina (EEL) is the preferred approach to guide stent sizing (down-sizing stent size based on cross-sectional EEL measurements) or lumen-based assessments (and upsizing stent size) when the EEL is not well visualized.¹² With CCTA, while luminal assessments can be obtained, there is variability in the use and dosage of nitroglycerin for image acquisition, and CCTA-based stent selection based on luminal assessments may underestimate vessel diameters compared with IVI.^19,20 Thus, IVI is considered a complementary approach to guiding stent size selection and stent optimization.  Overall, CCTA shows excellent agreement with IVI for plaque characterization and assessment of calcium burden, specifically calcium arc and calcium length. However, standardization of CCTA‑based stent sizing remains an opportunity for improvement, with need for additional studies.

Ongoing registry studies like the INVICTUS (Multicenter Registry of Invasive and Non-Invasive imaging modalities to compare Coronary Computed Tomography Angiography, Intravascular Ultrasound and Optical Coherence Tomography for the determination of Severity, Volume and Type of coronary atherosclerosis) registry aim to elucidate the agreement between CCTA and IVI in measuring the stent size and disease severity.²¹

Challenges also persist in differentiating between fibrous and fibro-fatty plaques due to similar Hounsfield units between these 2 types of plaques.²² Despite this, CCTA can identify high‑risk plaque features associated with increased risk of MI—particularly substantial plaque progression, positive remodeling, and low‑attenuation components—although this risk might be mediated by the overall atherosclerotic disease.^23,24 AI-driven plaque staging through a quantitative model holds promise for informing prognostic values based on plaque characteristics, although further validation is warranted.

3. CCTA physiology and virtual PCI

A key advantage of CCTA is the integration of anatomical and physiological data to guide invasive angiography and PCI. FFR_CT demonstrates diagnostic performance comparable to invasive pressure wire assessment and superior to perfusion imaging.^25,26

The CCTA virtual planner allows the performance of virtual PCI, offering benefits such as equipment selection, stent sizing, optimization of visualization angles, and pre- and virtually predicted post-procedural physiology. Predicted post-PCI FFR_CT has been validated against pressure-wire post-PCI FFR as well as angiographic post-PCI FFR.^26,27 This information allows individualized planning and may lead to improved prognosis by better selecting patients suitable for PCI. Currently, CCTA virtual modeling enables the prediction of post-PCI FFR_CT, while FFR_CT pullbacks offer data for analyzing the mismatch between functional and anatomical disease severity.²⁸ This virtual planning holds the potential to influence decision-making, as post-PCI FFR and stent length are independently associated with subsequent adverse cardiovascular events. For instance, FFR_CT pullback assessments can distinguish between diffuse and focal disease, providing valuable insights into the likelihood of residual angina post-PCI and the necessity of intervention.²⁹

In addition, CCTA can also assess the myocardial mass subtended, which is particularly relevant for bifurcation procedures, aiding in decision-making regarding side branch wire protection or stenting.^30-33

4. Clinical applications and unmet needs

CCTA plays a crucial role beyond diagnosis by providing guidance and enhancing preparedness for PCI procedures in the catheterization laboratory. CCTA integration facilitates optimized resource allocation, improved procedural outcomes, and shared decision-making between clinicians and patients. To date, randomized controlled trials (RCTs) have shown increased procedural efficiency with CCTA-guided PCI in patients with CTO and prior CABG. The clinical benefit of CCTA‑guided PCI is being evaluated in the ongoing P4 trial, while additional RCTs are warranted to better define patient and lesion subsets most likely to benefit.³⁴

Although CCTA exhibits some limitations in lesion assessment and characterization, these challenges can be addressed through integration with complementary imaging modalities.

The disparity in spatial-temporal resolution between CCTA and invasive intracoronary imaging underscores the challenges faced. Nonetheless, current discussions and available evidence do not sufficiently address practical barriers to real‑world implementation of CCTA-guided PCI, including scan‑to‑procedure time, reproducibility across CCTA vendors and software platforms, reimbursement considerations, data integration into the catheterization laboratory workflow, operator learning curves with CCTA interpretation, and the feasibility of adopting CCTA‑guided PCI in lower‑volume centers. Advancements in new AI-based tools may facilitate data extraction, accelerate the learning curve, and improve agreement between imaging modalities and physicians (Figure 3). Also, the co-registration of multiple techniques during PCI procedures offers synergistic benefits.

CCTA has evolved from a diagnostic modality to an important tool for preprocedural planning and PCI guidance. Broader adoption will require broader educational efforts, access to purpose-built software designed for ICs, and close collaboration with cardiac imaging physicians. While early data are promising, additional randomized and real-world studies are needed to define its impact on clinical outcomes and procedural efficiency.

Pedro E.P. Carvalho, MD¹; João L. Cavalcante, MD^1,2; Carlos Collet, MD, PhD³; Jonathon Leipsic, MD⁴; Omar K. Khalique, MD⁵; Victor Cheng, MD²; John Lesser, MD²; Bavana Rangan, BDS, MPH²; Emmanouil S. Brilakis, MD, PhD^1,2; Yader Sandoval, MD^1,2

From the ¹Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota; ²Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota; ³Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; ⁴Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada; ⁵St Francis Hospital and Heart Center, Roslyn, New York.

Acknowledgments: The authors would like to thank the Center for Coronary Artery Disease for its support in the first CCTA‑guided PCI initiative, with particular appreciation to Dimitris Strepkos, Michaella Alexandrou, Olga Mastrodemos, Deniz Mutlu, and Athanasios Rempakos.

Disclosures: Dr Leipsic is a consultant for, and holds stock options in Heartflow. Dr Khalique is a consultant for Heartflow, Siemens, and Philips. Dr Cheng serves as a scientific advisor for Cleerly Health. Dr Brilakis receives consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Boston Scientific, the Cardiovascular Innovations Foundation (Board of Directors), Cordis, Elsevier, GE Healthcare, Heartflow, IMDS, Medtronic, Recor Medical, Shockwave, SIS Medical, Teleflex, and Terumo; receives research support from AngioWave, Boston Scientific, and GE Healthcare; is the owner of Hippocrates LLC and Systole LLC; and is a shareholder in Cleerly Health, LifeLens Technologies, Inc., MHI Ventures, Stallion Medical, and TrueVue, Inc.  Dr Sandoval reports relationships with Abbott Vascular (consultant, advisory board, speaker); Boston Scientific (consultant); CathWorks (consultant, speaker); Cleerly Health (speaker, research grant); GE Healthcare (consultant, advisory board, speaker); HeartFlow (consultant, advisory board, speaker, research grant); Medtronic (speaker); Philips (consultant, advisory board, speaker); Roche Diagnostics (consultant, advisory board, speaker); Siemens (consultant, advisory board); and Shockwave Medical (research/education grant); and jointly holds patent 20210401347. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Yader Sandoval, MD, FACC, FSCAI, FESC, Minneapolis Heart Institute, Abbott Northwestern Hospital and Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 300, Minneapolis, MN 55407, USA. Email: yadersandoval@gmail.com; X: @yadersandoval