Coronary CT Angiography in PCI Planning: Advances, Clinical Applications, and Challenges

Background: Interventional cardiology is increasingly being reshaped by rapid progress in non-invasive cardiovascular imaging. Coronary computed tomography angiography (CTCA), once used mainly to exclude obstructive coronary artery disease (CAD), is now being adopted as a broader planning instrument before percutaneous coronary intervention (PCI). Its ability to generate high-resolution three-dimensional visualization of the coronary tree, together with functional assessment through CT-derived fractional flow reserve (FFR-CT) and more advanced plaque analysis supported by artificial intelligence (AI), has expanded its relevance from diagnosis alone to strategic procedural preparation. In this setting, CTCA can help refine lesion assessment, anticipate technical complexity, and support better procedural and clinical outcomes. Technological Advancements: The value of CTCA for both diagnosis and risk stratification has increased substantially with recent technical innovation. Among the most important developments is the maturation of FFR-CT, which enables non-invasive physiological interrogation of coronary stenoses using computational modeling. At the same time, artificial intelligence and deep learning tools are reshaping the CTCA workflow by improving automation, facilitating plaque analysis, and highlighting adverse plaque characteristics such as positive remodeling, spotty calcification, and the napkin-ring sign. Clinical Applications: In modern catheterization practice, CTCA is increasingly used to address anatomically demanding scenarios. Its role is particularly valuable in chronic total occlusion (CTO) intervention, where it can delineate occlusion length, stump characteristics, vessel course, and collateral anatomy before the procedure. Its usefulness also extends beyond CTO PCI by supporting vessel sizing, stent planning, and anticipation of lesion preparation requirements in complex coronary disease. Challenges: Despite these advantages, several barriers continue to limit wider implementation, including blooming from heavy calcification, radiation burden, contrast-related renal concerns, and the practical difficulty of embedding CTCA-based planning into routine workflows. Conclusion: CTCA is becoming an increasingly important adjunct in PCI planning because it can combine anatomical definition, physiological interpretation, and plaque-level information before invasive treatment is undertaken. Overall, this review emphasizes CTCA not only as a diagnostic modality, but also as a practical pre-procedural roadmap that can guide lesion selection, stent planning, calcium modification strategies, and overall PCI strategy.