The Role of Coronary Computed Tomography Angiography in Chronic Total Occlusion-Percutaneous Coronary Intervention (JACC Cardiovascular Interventions January 2026)-Article: The Role of Coronary Computed Tomography Angiography in Chronic Total Occlusion-Percutaneous Coronary Intervention

Article: The Role of Coronary Computed Tomography Angiography in Chronic Total Occlusion-Percutaneous Coronary Intervention

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This 2026 state-of-the-art review discusses the evolving role of coronary computed tomography angiography (CTA) in planning and guiding percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs)—complete blockages of coronary arteries. CTO PCI is technically challenging, requiring detailed lesion assessment and procedural planning.<br /><br />Coronary CTA offers three-dimensional visualization enhancing diagnosis and comprehensive lesion characterization, including cap morphology, occlusion length, calcification patterns, distal vessel quality, and collateral circulation. Compared with invasive coronary angiography (CAG), CTA better delineates occlusion length and calcium severity, including distinct patterns like “full moon” calcification linked to procedural difficulty and risk. It also improves assessment of distal vessel quality, which influences strategy selection.<br /><br />The review highlights that preprocedural coronary CTA improves technical success and reduces complications, especially in complex CTOs exhibiting blunt stumps, long length (>20mm), or severe calcification. The randomized CT-CTO trial showed a significant increase in CTO PCI success (93.5% vs 84%) when coronary CTA was used for planning, particularly for difficult cases (J-CTO score ≥2). CTA can resolve proximal cap ambiguity, a major factor for procedural failure, and predict guidewire crossing time using various CTA-based scoring systems.<br /><br />Integration of artificial intelligence (AI) with coronary CTA promises automated lesion detection, plaque characterization, and success prediction but awaits wider validation and regulatory approval. Real-time coregistration of CTA with fluoroscopy, including augmented reality visualization, can facilitate wire navigation during PCI, though further improvements are needed for routine use.<br /><br />Practical implementation involves systematic CTA image review (maximum intensity projection, axial, and multiplanar reconstructions), aiding lesion assessment and procedural planning. However, CTA-guided CTO PCI adoption is limited due to operator experience gaps, reimbursement issues, and workflow challenges, despite demonstrated benefits.<br /><br />The authors advocate for broader clinician training, streamlined reimbursement, user-friendly AI tools, and real-time imaging integration to enhance coronary CTA’s role, ultimately improving CTO PCI outcomes and patient safety.

Keywords

coronary computed tomography angiography

CTO PCI

chronic total occlusions

lesion assessment

percutaneous coronary intervention

artificial intelligence in cardiology

coronary artery calcification

preprocedural planning

CT-CTO trial

real-time imaging integration