Systematic Review of Coronary Computed Tomography Angiography Guidance for Chronic Total Occlusion Percutaneous Coronary Intervention

Clinical Snapshot

Key Findings

• P Value: Not reported at the systematic review level

• Effect Size: Not quantified — narrative synthesis only. Authors report that preprocedural CCTA improves procedural planning and increases technical success in complex lesions, particularly those incompletely defined by conventional angiography

• Primary Outcome: Role of CCTA in CTO PCI across four domains: (1) CTO diagnosis, (2) lesion characterisation (proximal/distal cap morphology, vessel course, calcification, tortuosity, collateral anatomy), (3) prediction of guidewire crossing and procedural success, and (4) real-time procedural guidance via fluoroscopic co-registration

• Nnt Or Sensitivity: Not reported. Individual included studies likely report diagnostic sensitivity/specificity for lesion characterisation and odds ratios for procedural success prediction, but these are not synthesised in the abstract. CCTA-derived CTO scoring systems (e.g., CT-RECTOR, KCCT score) referenced in the literature provide lesion-level predictive metrics but pooled estimates are absent from this review.

• Confidence Interval: Not reported — no pooled estimates provided

Clinical Application

CCTA for CTO PCI planning requires 64-slice or higher CT scanners (ideally ≥256-slice or photon-counting CT for optimal spatial resolution), dedicated cardiac CT expertise for acquisition and post-processing, and 3D reconstruction software for fluoroscopic co-registration. Feasibility is high at tertiary cardiac centres but limited in regional and rural settings. Radiation and contrast exposure from CCTA must be weighed against procedural benefit, particularly in patients with chronic kidney disease. In Australia, CCTA is MBS-rebatable for coronary artery disease assessment (MBS items 57360–57363), though specific reimbursement for CTO PCI planning is not a discrete MBS indication. High-volume CTO PCI programmes exist at major metropolitan centres (e.g., Alfred Hospital Melbourne, Royal Prince Alfred Sydney, Prince Charles Hospital Brisbane). The TGA has approved relevant CT platforms and co-registration software. CCTA-guided CTO PCI aligns with NHFA/CSANZ guidelines supporting optimal procedural planning for complex PCI. PBS listing of antiplatelet and anticoagulant therapies used in CTO PCI (ticagrelor, prasugrel, bivalirudin) is established. RACGP and CSANZ would likely support CCTA as an adjunct in appropriately selected complex CTO cases at specialist centres, consistent with the Heart Foundation's position on advanced cardiac imaging. Cost-effectiveness data specific to the Australian healthcare system are lacking and represent a research priority. Adults with angiographically confirmed or suspected CTOs being evaluated for PCI, particularly those with complex lesion anatomy (ambiguous proximal cap, tortuous or calcified vessel course, prior failed PCI attempt, or high J-CTO score ≥2). Most applicable to patients at high-volume CTO PCI centres with access to dedicated cardiac CT programmes.

Abstract

Coronary computed tomography angiography (CCTA) is emerging as a valuable adjunct for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), particularly for lesions in which angiography incompletely defines procedural anatomy. In this systematic review, the authors evaluated the role of CCTA in CTO diagnosis, lesion characterization, prediction of guidewire crossing and procedural success, and procedural guidance. CCTA provides a detailed assessment of key features that directly influence CTO PCI strategy and outcomes. Randomized and observational data suggest that preprocedural CCTA can improve procedural planning, increase technical success in complex lesions, and support safer and more efficient CTO PCI through fluoroscopic co-registration and other real-time guidance applications. These findings highlight the clinical value of CCTA as a tool that can enhance case selection, optimize crossing strategy, and improve procedural success in contemporary CTO PCI.

References

1. 1.Kumar, S., Carvalho, P. E. P., Strepkos, D., Alexandrou, M., Opolski, M. P., Azzalini, L., Alaswad, K., Basir, M. B., Jaffer, F., Collet, C., Leipsic, J., Cavalcante, J., Rangan, B. V., Sandoval, Y., & Brilakis, E. S. (2026). Systematic review of coronary computed tomography angiography guidance for chronic total occlusion percutaneous coronary intervention. The American Journal of Cardiology. Advance online publication. https://doi.org/10.1016/j.amjcard.2026.04.045