CCTA helping more and more cardiologists plan ahead before PCI

"CT preparation for PCI is really going to be a hot topic for PCI planning," Seto said. "We already increasingly are getting CT data prior to people presenting to the cath lab. And really, as interventionalists, we need to know how to analyze that data to better triage a patient to either a high-risk or low-risk lab, to plan ahead as to what equipment might be needed and how long they might need, and potentially to rule out people who just may not need angiography."

CT also offers a view of coronary anatomy and disease across all three major coronary arteries, potentially providing a more comprehensive assessment of disease burden than invasive, wire-based fractional flow reserve (FFR) measurements alone, Seto said.

He added that CCTA is becoming a gate keeper for the cath lab. This is helping reduce the number of diagnostic angiograms that do not lead to a PCI.

"The guidelines are all supportive of CT as the initial gateway," Seto said. "And frankly, nuclear medicine, it's a 60-year-old technology that's always been known as 'unclear medicine' because it always leaves us guessing. I think, from the interventionalist standpoint, we're going to see more CTs increasingly as some of these older technologies fade out."

He added that the U.S. is ready behind some nations. In the UK, for example, CCTA has been implemented as a primary stress test modality.

The movement toward more CCTA preplanning is evident when reviewing the schedules for various cardiology meetings such as TCT 2026. Prior to 2020, it was not common to see CT imaging included in sessions or case reports, but that have changed in recent years. The modality is now included alongside angiogram images in presentations, and there have been specialized training sessions for interventional cardiologists to lean how to navigate CCTA post-processing and to read the scans.

Adoption grows, but limitations remain

Seto said he is seeing more CCTA use in both Veterans Affairs facilities and private practices. Wider insurance coverage for services such as HeartFlow's FFR-CT physiologic assessment and coronary plaque analysis is helping expand access to these technologies. Additionally, clinical guidelines are now supporting CT as an initial test for evaluating suspected coronary artery disease.

He expects CCTA to gain ground as some older nuclear imaging approaches lose favor among clinicians, but noted CT is not appropriate for every patient. Heavy coronary calcification, which Seto said is common among veterans, can make CT findings difficult to interpret. Previous coronary stents can also limit assessment. In these cases, physicians may still need functional stress testing or an invasive evaluation.

Implementing CT also requires additional staffing and time compared with nuclear imaging workflows. Patients may need beta-blockers to lower their heart rates, nursing support and additional observation, creating operational challenges for hospitals and imaging departments.

Despite these limitations, Seto said he has advocated for greater use of CT in the VA system, citing its potential to provide more detailed anatomical information before an invasive procedure.

Reimbursement could determine adoption

Looking five to 10 years ahead, Seto expects pre-procedure planning to become a more established part of interventional cardiology, particularly for patients whose procedures can be scheduled in advance. Knowing the extent of disease and understanding coronary anatomy before entering the catheterization lab could help physicians anticipate device requirements, including guide catheters and stent sizes, and better estimate how long a procedure will take.

That predictability could be valuable for busy catheterization labs managing tight schedules and patients awaiting treatment. However, emergency ST-elevation myocardial infarction (STEMI) procedures will continue to require physicians to make rapid decisions without the benefit of advance planning, he said.

The business challenge is determining how physicians will be compensated for reviewing CT scans and developing procedural plans. Seto said SCAI is pursuing advocacy efforts to explore whether a dedicated billing code or reimbursement mechanism could support this work. Establishing reimbursement may require evidence that CT-based planning involves a distinct workflow or improves outcomes beyond what is achieved through existing pre-procedure assessments, he said.

The amount of time physicians devote to reviewing scans may also vary. Some may spend 20 to 30 minutes conducting a detailed assessment, while others may perform a brief review to identify major features such as extensive calcification or three-vessel disease.

Seto expects practice patterns to differ according to patient populations, staffing, reimbursement and individual clinical workflows.

While the technology offers an opportunity to make PCI more predictable, he said, its broader adoption will depend not only on the clinical value of CT but also on whether healthcare systems can accommodate and compensate physicians for the additional planning involved.