The current state and challenges of coronary computed tomography angiography-guided percutaneous coronary intervention among participating institutions in the Chinese mainland: a multicenter cross-sectional survey

Introduction

Coronary computed tomography angiography (CCTA) is an established non-invasive test for suspected coronary artery disease. Guidelines support CCTA as an early or first-line test in selected patients because it can exclude obstructive disease, define anatomy, detect atherosclerosis and guide prevention (1-3). Randomized trials in stable chest pain have shown improved diagnostic certainty and management versus usual care or functional testing alone (4,5). Standardized acquisition and reporting systems, including SCCT consensus documents and CAD-RADS 2.0, have reinforced its diagnostic role (6,7). However, CCTA often remains a diagnostic gatekeeper rather than a procedural planning tool.

Technical advances in scanner hardware, motion correction, image reconstruction, artificial intelligence (AI) and post-processing now allow CCTA to provide information beyond binary stenosis assessment. A high-quality CCTA dataset can define lesion location, ostial origin, vessel course, reference vessel size, lesion length, plaque composition, remodeling, calcification length and arc, vessel tortuosity, bifurcation geometry, side-branch anatomy, distal landing zones and pericoronary or vascular wall features (8-11). Functional extensions, including CT-derived fractional flow reserve (CT-FFR), translesional CT-FFR gradient and stress CT myocardial perfusion, can estimate lesion-specific ischemia and perfusion abnormalities (12-18). These parameters create a basis for using CT to anticipate procedural difficulty and support individualized percutaneous coronary intervention (PCI) planning.

The concept of CCTA-guided PCI has emerged as a strategy in which CCTA information is reviewed and integrated into PCI planning through collaboration between interventional cardiologists and imaging specialists (8,19,20). Rather than replacing invasive angiography, intravascular imaging or invasive physiology, CCTA-guided PCI provides a preprocedural roadmap for lesion selection, complex anatomy, projection planning, calcium modification, stent sizing, bifurcation strategy, chronic total occlusion (CTO) crossing strategy and adjunctive device preparation (Figure 1) (8,19-23). Although international interest is increasing, implementation remains exploratory and heterogeneous. In the Chinese mainland, CCTA use and imaging-data accumulation have grown rapidly, as reflected by large-scale Chinese CCTA imaging resources and multicenter CT-FFR studies (16,17,24). However, its use beyond diagnostic assessment to support structured PCI-oriented workflows remains unclear. We therefore conducted a multicenter cross-sectional survey to describe the current state, perceived value, available tools and barriers to CCTA-guided PCI among participating institutions in the Chinese mainland, with attention to CT-FFR, CT myocardial perfusion and PCI-oriented post-processing. We present this article in accordance with the SURGE reporting checklist (available at https://rx.amegroups.com/article/view/10.21037/rx-26-0072/rc).

Figure 1 CCTA-guided PCI workflow from preprocedural CCTA to procedural strategy. Representative CCTA-derived information that may support PCI planning includes coronary anatomy and vessel course; lesion and ostial localization; CT-FFR-based physiology and virtual intervention planning; myocardial territory and bifurcation assessment; calcium morphology and lesion preparation; projection planning and CCTA-angiography fusion; and multiplanar reconstruction for lesion measurement and stent sizing. The workflow is intended primarily for selected patients in whom preprocedural CT information is likely to influence procedural strategy, particularly complex PCI, and requires close collaboration between interventional cardiology and cardiac imaging. Figure 1 was adapted and entirely redrawn from the Central Illustration in Sandoval et al. (19), with permission from Elsevier (Copyright Clearance Center RightsLink License No. 6335860706311; license date: August 25, 2026) (Appendix 2). CAD, coronary artery disease; CCTA, coronary computed tomography angiography; CT, computed tomography; CT-FFR, CT-derived fractional flow reserve; LCA, left coronary artery; MIP, maximum-intensity projection; MPR, multiplanar reconstruction; PCI, percutaneous coronary intervention; RCA, right coronary artery.

Methods

Study design, sampling, and participants.

This multicenter cross-sectional questionnaire-based survey was conducted between March 9 and April 30, 2026 among participating centers in the Chinese mainland involved in cardiac CT imaging or PCI. After the questionnaire was finalized, the survey link was openly disseminated through the National Cardiovascular Imaging Quality Control Center platform/network, the Chinese Non-Invasive Cardiovascular Imaging and Physiology Club (CHART), the Oriental Huaxia Cardiovascular Health Research Institute (Suzhou Industrial Park), China Cardiovascular Association, study groups, and professional academic networks. No institutions were preselected or individually invited according to a predefined sampling frame, and participation was voluntary. Accordingly, the total number of institutions exposed to the survey link could not be enumerated, and a formal response rate could not be calculated.

Given the descriptive, voluntary-response design and absence of a predefined sampling frame, no formal sample size calculation was performed. The electronic questionnaire required completion of all mandatory items before submission. Submitted questionnaires were screened for data quality and usability; responses containing non-interpretable institutional information or clearly erroneous core data that rendered the questionnaire unusable were excluded. Of 111 submitted questionnaires, 2 were excluded after data-quality screening, leaving 109 valid departmental questionnaires from 108 institutions (36 cardiology and 73 radiology) (Figure S1). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Ethics Committee of Fuwai Hospital (approval No. 2026-3087). This questionnaire-based survey evaluated institutional practice patterns and physicians’ perceptions and did not involve patient intervention, patient-level clinical data, biological specimens, or identifiable patient information. The requirement for written informed consent was waived by the ethics committee. Survey participation was voluntary, and the results were analyzed at the aggregate level.

Questionnaire content and survey administration

The questionnaire was developed according to the study objectives and CCTA-guided PCI workflow, reviewed by cardiac imaging and interventional cardiology investigators for clarity, completeness and face validity, and provided in full in Appendix 1. It was not a psychometric scale, so formal scale validation and scoring procedures were not applicable.

The questionnaire collected annual procedural and imaging volumes, availability of cardiovascular CT technologies, clinical practice patterns, CT-based PCI planning tools, perceived clinical value, and implementation barriers. Historical annual volumes were recorded for each calendar year from January 1, 2016 through December 31, 2025. CCTA/CT-FFR volumes and cardiovascular CT technology availability were derived from radiology responses, whereas PCI volumes were derived from cardiology responses. Among the 109 valid responses, 107 were recorded as accessing the questionnaire through WeChat and 2 through a direct web link. One response per department/institution was encouraged, no incentives were offered, and no item-level imputation was required. Cardiology and radiology questionnaires were not systematically paired within institutions; only one institution contributed valid responses from both departments, and these departmental responses were analyzed according to their respective questionnaire domains.

Statistical analysis

Statistical analyses were performed using R software, version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Categorical variables were summarized as counts and percentages, and skewed continuous variables as medians and interquartile ranges. For multiple-choice questions, the numerator was the number selecting each item and the denominator was the total number of valid questionnaires or the relevant prespecified subgroup. Annual PCI, CCTA, and CT-FFR volumes from 2016 to 2025 were summarized descriptively overall and, where applicable, by geographic region and hospital tier. Between-group comparisons used the Mann-Whitney U test, Chi-squared test, or Fisher exact test, as appropriate. All tests were two-sided, with P<0.05 considered statistically significant.

An exploratory weighted ranking method was used to evaluate the perceived importance of CT features during PCI guidance. The first-ranked feature was assigned 12 points, the second-ranked feature 11 points and subsequent ranks progressively fewer points; unselected items were assigned 0 points. Higher weighted scores indicated greater perceived importance.

This study characterized current practice patterns, perceived barriers, and technology availability among participating institutions; it was not designed to assess diagnostic accuracy, procedural efficacy, patient outcomes, or population-weighted national utilization. Inferential comparisons were therefore considered exploratory.

Use of AI-assisted tools

ChatGPT (OpenAI, version 5.0) was used only to assist with the generation, layout, and visual refinement of the graphical abstract and Figure 2, based strictly on the scientific content, data, and key visual elements provided by the authors. All AI-assisted figures were subsequently reviewed, verified, and revised by the authors to ensure scientific accuracy and consistency with the underlying data. AI was not used for study design, questionnaire development, data collection, statistical analysis, interpretation of the results, or generation of the scientific conclusions.

Figure 2 Geographic distribution of valid questionnaires across the Chinese mainland. Geographic distribution of 109 valid departmental questionnaires across 30 provincial-level administrative regions in the Chinese mainland after standardization of province names. Numbers indicate valid questionnaires. The five highest counts were from Shandong (n=10), Guangdong (n=9), Jiangsu (n=8), Hebei (n=7), and Fujian (n=6). Hong Kong, Macao, and Taiwan were not included in the survey analysis.

Results

Survey sample and geographic distribution

After exclusion of two questionnaires with invalid or clearly erroneous responses, 109 complete and valid departmental questionnaires from 108 institutions were included: 36 cardiology and 73 radiology questionnaires. Only one institution (Guangdong Province, tertiary grade A) contributed valid responses from both departments; therefore, the department-specific responses were not treated as matched pairs. The 108 institutions covered 30 provincial-level administrative regions in the Chinese mainland (Figure 2). Across the seven geographic regions, 109 valid questionnaires were distributed as follows: East Chinese mainland, 36/109 (33.0%); North, 19/109 (17.4%); South, 17/109 (15.6%); northeastern, 10/109 (9.2%); Central, 10/109 (9.2%); southwestern, 10/109 (9.2%); and northwestern, 7/109 (6.4%). Among the 108 unique institutions, 70/108 (64.8%) were tertiary grade A, 6/108 (5.6%) tertiary grade B, 10/108 (9.3%) tertiary with grade unspecified, 20/108 (18.5%) secondary grade A, 1/108 (0.9%) secondary grade B, and 1/108 (0.9%) secondary with grade unspecified.

Annual PCI, CCTA and CT-FFR volumes

Annual procedural volumes and temporal trends from 2016 to 2025 are shown in Figure 3 and Table 1; stratified regional and hospital-tier trends are shown in Figure S2 and Figure S3, respectively. The surveyed cardiology centers had established PCI experience, but inter-center variability was substantial. In 2025, the median annual PCI volume was 572 cases (IQR, 332-1,732) and the mean was 1,773 cases. Median annual PCI volume increased from 272 cases in 2016 to 572 cases in 2025. CCTA activity was substantially higher and showed a more pronounced increase. Among radiology respondents, median annual CCTA volume increased from 500 cases in 2016 to 3,905 cases in 2025, with a total reported volume of 840,078 cases in 2025 (Table 2). Total annual CT-FFR volume increased from 1,627 cases in 2016 to 70,523 cases in 2025, while the median annual CT-FFR volume remained 0 throughout the study period. Non-zero CT-FFR activity was reported by only 33 of 73 radiology centers (45.2%).

Figure 3 Temporal trends in annual PCI, CCTA, and CT-FFR activity from 2016 to 2025. Lines show the median annual PCI volume among cardiology respondents (n=36), the median annual CCTA volume among radiology respondents (n=73), and the median annual CT-FFR volume among radiology respondents (n=73). The median annual CT-FFR volume remained 0 in every year, although total CT-FFR activity increased from 1,627 analyses in 2016 to 70,523 in 2025 (Table 2), reflecting concentration of activity in a subset of centers. CCTA, coronary computed tomography angiography; CT, computed tomography; CT-FFR, CT-derived fractional flow reserve; PCI, percutaneous coronary intervention.

Median annual PCI volume increased in all represented regions, including East Chinese mainland from 245 to 814 cases, North from 350 to 500, Central from 438 to 876, and South from 400 to 2,000.5 cases. CCTA volume also increased markedly, particularly in North (3,310 to 10,005), northeastern (1,620 to 14,297.5), Central (0 to 10,984), and northwestern Chinese mainland (2,595 to 11,482). Regional CT-FFR activity remained uneven; by 2025, non-zero CT-FFR activity was reported by 4/5 northwestern (80.0%), 7/9 southwestern (77.8%), 6/10 North (60.0%), and 9/21 East Chinese mainland (42.9%) radiology respondents.

Median annual PCI volume increased from 600 to 1,473 cases in tertiary grade A centers, compared with 126 to 501 in tertiary grade B, 52 to 360 in tertiary grade-unspecified, and 0 to 169 in secondary grade A centers. Among radiology respondents, median CCTA volume in tertiary grade A centers increased from 2,298.5 to 11,169 cases, exceeding most other tiers. In 2025, non-zero CT-FFR activity was reported by 29/48 tertiary grade A (60.4%), 1/3 tertiary grade B (33.3%), 2/5 tertiary grade-unspecified (40.0%), and 1/15 secondary grade A (6.7%) radiology respondents. For the detailed hospital-tier analysis, cardiology respondents comprised 23 tertiary grade A, 3 tertiary grade B, 5 tertiary with grade unspecified, and 5 secondary grade A centers; there were no cardiology respondents from secondary grade B or secondary with grade unspecified hospitals. No cardiology respondents were available from the northeastern regional subgroup. Because several regional and hospital-tier strata were small, these subgroup analyses are descriptive rather than population-level comparisons. Detailed subgroup composition for the regional and hospital-tier analyses is provided in Table S1.

Frequency of CT use for PCI planning in 2025

In response to the survey item asking how often CT was used for PCI planning during 2025, 22/109 respondents (20.2%) reported no use, 43/109 (39.4%) reported use in <10% of PCI cases, 32/109 (29.4%) reported use in 10-50%, and 12/109 (11.0%) reported use in >50%. Because this item was reported at the departmental level and did not capture patient-level linkage between a specific preprocedural CCTA and a subsequent PCI, it should be interpreted as a measure of practice frequency rather than a verified rate of formally CCTA-guided PCI.

Availability of advanced cardiac CT equipment and technologies

CCTA was available in all 73 radiology centers. CT-FFR was available in 40/73 centers (54.8%), CT myocardial perfusion in 21/73 (28.8%) and photon-counting CT in 9/73 (12.3%) (Figure 4).

Figure 4 Availability and representative examples of advanced cardiovascular CT technologies. (A) Availability of cardiovascular CT technologies and equipment among radiology respondents (n=73). Bars show the number and proportion of centers reporting availability. (B) Representative CT-FFR analysis demonstrating lesion-specific physiological assessment. (C) Representative CT myocardial perfusion images demonstrating color-coded myocardial perfusion assessment. CCTA, coronary computed tomography angiography; CT, computed tomography; CTA, computed tomography angiography; CT-FFR, CT-derived fractional flow reserve.

Availability of CT-based PCI guidance tools

The most widely available CT-based PCI planning tools were morphological and quantitative. Plaque and calcification assessment was available to 92/109 respondents (84.4%), coronary centerline and luminal measurements to 81/109 (74.3%), CT-FFR for PCI planning to 64/109 (58.7%), and lesion-length or stent-size evaluation to 62/109 (56.9%). Less widely available applications included luminal or pericoronary inflammatory features [45/109 (41.3%)], CT myocardial perfusion [31/109 (28.4%)], three-dimensional bifurcation planning [30/109 (27.5%)], and CTO crossing strategy planning [25/109 (22.9%)] (Figure S4).

Perceived clinical value and importance ranking of CT features for PCI guidance

Overall, respondents perceived CT to be most useful in complex anatomical and lesion settings. Differences between cardiology and radiology groups in perceptions of CT-related PCI guidance are shown in Figure 5. Determination of lesion location or coronary ostial position was the most frequently selected application in both groups, reported by 28/36 cardiology respondents (77.8%) and 63/73 radiology respondents (86.3%). Among cardiology respondents, the top three perceived applications were lesion or ostial localization [28/36 (77.8%)], CTO guidance [27/36 (75.0%)] and severe calcified lesions [26/36 (72.2%)]. Among radiology respondents, the top perceived applications were lesion or ostial localization [63/73 (86.3%)], left main bifurcation assessment [53/73 (72.6%)] and severe calcified lesions [51/73 (69.9%)], followed by CT-FFR-based ischemia assessment [49/73 (67.1%)]. Compared with cardiology respondents, radiology respondents more frequently emphasized left main bifurcation [53/73 (72.6%) vs. 12/36 (33.3%), P<0.001], bifurcation lesions [44/73 (60.3%) vs. 10/36 (27.8%), P=0.003], side-branch assessment [40/73 (54.8%) vs. 7/36 (19.4%), P=0.001], functional and tissue characteristics of downstream ischemic myocardium [37/73 (50.7%) vs. 9/36 (25.0%), P=0.019], and plaque, vessel wall or pericoronary fat attenuation/inflammatory features [47/73 (64.4%) vs. 7/36 (19.4%), P<0.001].

Figure 5 Perceived value of CT for PCI guidance and weighted importance of CT features. (A) Comparison of perceived clinical contributions of CT to PCI guidance between cardiology (n=36) and radiology (n=73) respondents. (B) Comparison of weighted importance scores for CT features used in PCI planning. For the ranking analysis, the first-ranked feature received 12 points, the second 11 points, and subsequent ranks progressively fewer points; unranked items received 0 points. Panel A group comparisons used Chi-squared or Fisher exact tests as appropriate; panel B used the Mann-Whitney U test. CCTA, coronary computed tomography angiography; CT, computed tomography; CTA, computed tomography angiography; CT-FFR, CT-derived fractional flow reserve; PCI, percutaneous coronary intervention.

Weighted ranking analysis showed that while traditional lumen-centered and function-centered features were regarded as most important, the perceived importance of individual CT features differed between cardiology and radiology respondents (Figure 5). Among radiology respondents, the three highest-ranked features were degree of coronary stenosis (weighted score, 10.1), plaque composition and characteristics (8.2) and lesion length (7.0), followed by CT-FFR (6.7). Among cardiology respondents, the highest-ranked features were degree of coronary stenosis (8.6), CT-FFR (7.7), and plaque composition/characteristics and severity of calcification (both 7.2). Cardiology respondents assigned higher importance than radiology respondents to fusion of coronary CTA and invasive coronary angiography (5.2 vs. 2.8, P=0.003) and severity of calcification (7.2 vs. 5.9, P=0.042), whereas radiology respondents assigned higher importance to degree of coronary stenosis (10.1 vs. 8.6, P=0.040).

Barriers to CT-FFR application

Although the relative ranking of barriers differed slightly between cardiology and radiology respondents, no statistically significant between-group differences were observed for any item (all P>0.05) (Figure 6). Among radiology respondents, the three most frequently selected barriers to CT-FFR implementation were inadequate awareness of CT-FFR among relevant departments or physicians [57/73 (78.1%)], absence of billing codes [52/73 (71.2%)] and limited patient familiarity with CT-FFR [43/73 (58.9%)]. Among cardiology respondents, the leading barriers were inadequate awareness [25/36 (69.4%)], absence of billing codes [24/36 (66.7%)] and high cost or lack of reimbursement [17/36 (47.2%)]. Limited patient familiarity was reported by 16/36 cardiology respondents (44.4%). Perceived low accuracy was reported by 7/36 cardiology respondents (19.4%) and 7/73 radiology respondents (9.6%), and limited impact on treatment decision-making by 5/36 (13.9%) and 3/73 (4.1%), respectively.

Figure 6 Perceived barriers to clinical implementation of CT-FFR. Comparison of perceived barriers to CT-FFR implementation between cardiology (n=36) and radiology (n=73) respondents. Bars show the proportion selecting each item. P values are from Chi-squared tests with Yates correction or Fisher exact tests, as appropriate. No between-group difference reached statistical significance. CT, computed tomography; CT-FFR, CT-derived fractional flow reserve.

Stable chest pain evaluation and perceived difficulties in CCTA-guided PCI.

Among cardiology respondents, CCTA was the most frequently selected first-line test for routine evaluation of stable chest pain, chosen by 26/36 respondents (72.2%); invasive coronary angiography was selected by 6/36 (16.7%) and myocardial perfusion imaging by 4/36 (11.1%). A single-choice follow-up asked the primary reason for selecting CCTA rather than functional testing; 21/36 (58.3%) selected guideline-based exclusion of coronary artery disease in low- to intermediate-risk patients. Other responses included anatomical planning before PCI, need for more precise anatomy, local hospital preference or test availability, ambiguous previous functional test results, and other reasons (Table S2). Because only one primary reason could be selected, this item does not capture all factors influencing real-world clinical decisions. The main perceived difficulties in implementing CCTA-guided PCI were lack of trained readers or post-processing staff, physician reliance on invasive angiography, lack of software or post-processing tools, image-quality limitations, and calcification or stent artifacts (Figure S5).

Discussion

This multicenter cross-sectional survey provides a contemporary assessment of CCTA-guided PCI implementation among participating institutions in the Chinese mainland. Several findings merit emphasis. PCI and CCTA volumes increased from 2016 to 2025, but translation of this capacity into PCI planning remained incomplete: 87/109 respondents (79.8%) reported some CT use for PCI planning in 2025, whereas only 12/109 (11.0%) reported use in >50% of PCI cases. Available CT-based PCI guidance tools were predominantly morphological and quantitative, whereas advanced functional and procedure-specific applications were less accessible. CT was perceived as particularly useful in complex PCI, and stenosis severity, CT-FFR, plaque characteristics, calcification severity, and lesion length were among the highest-ranked features for procedural planning. Major barriers centered on physician awareness, billing and reimbursement, patient familiarity, and trained personnel/post-processing resources.

The survey findings suggest a stepwise implementation gap between diagnostic CCTA capacity and structured PCI-oriented use. CCTA was universally available among participating radiology departments, whereas frequent use for PCI planning and access to advanced functional or procedure-specific tools were less common. CT-FFR occupied an intermediate position: aggregate activity increased, but the median annual volume remained 0 and non-zero activity was concentrated in a subset of radiology centers. This pattern suggests that increasing CCTA availability alone is insufficient; effective implementation also requires reliable translation of diagnostic datasets into reproducible, procedure-oriented information. A 2016 cross-sectional survey of 152 tertiary hospitals in the Chinese mainland reported a median annual cardiac CT volume of 1,037 examinations (25), whereas the median annual CCTA volume among participating radiology centers in the present survey reached 3,905 in 2025. These surveys are not directly comparable because of differences in sampling and definitions, but they provide context for the expansion of cardiac CT capacity. Internationally, a cross-sectional survey of 25 P4 investigators reported high perceived utility of preprocedural CCTA, particularly for plaque and calcium characterization (26). Our survey similarly ranked plaque, calcification, stenosis severity, and CT-derived physiology highly, but additionally demonstrates that perceived value does not necessarily translate into routine implementation across heterogeneous institutions, as frequent CT use for PCI planning and advanced procedural-planning tools remained limited.

CCTA-guided PCI should be understood as a procedural strategy rather than the simple availability of a CCTA report before invasive angiography. Expert opinion and review articles describe a workflow in which preprocedural CCTA is systematically reviewed and post-processed into lesion-specific, procedure-oriented information for treatment selection, procedural planning, device preparation, and intraprocedural execution (19,20). In this framework, CCTA becomes a structured planning dataset jointly interpreted by interventional cardiologists and cardiac imaging specialists to identify targets, characterize vessel and plaque morphology, anticipate procedural difficulty, and communicate an individualized revascularization plan. This distinction is important because high CCTA volume or software availability does not by itself indicate a mature CCTA-guided PCI workflow. Likewise, the departmental frequency item in this survey reflects reported CT use for PCI planning rather than a verified patient-level rate of formally CCTA-guided PCI.

The potential value of CCTA-guided PCI derives from the multidimensional information available from CCTA. Beyond the contrast-filled lumen depicted by invasive angiography, CCTA can characterize vessel course, ostial origin, lesion length, reference vessel size, tortuosity, bifurcation anatomy, side-branch involvement, distal landing zones, calcified and non-calcified plaque, plaque burden, high-risk plaque features, and pericoronary tissue characteristics (6-11). Functional extensions include CT-FFR, translesional CT-FFR gradients, CT myocardial perfusion, and myocardial territory assessment (12-18). Dai et al. further showed that CCTA-derived plaque characteristics and physiological disease patterns can be evaluated together and may help predict peri-procedural myocardial infarction and subsequent events (11). These multidimensional capabilities of anatomical, plaque-related, and physiological features were highly valued by respondents for procedural planning.

Clinically, CCTA-guided PCI may shift coronary revascularization from angiography-centered decision-making toward image- and physiology-informed procedural planning. Contemporary revascularization guidelines and invasive physiology studies support integrating anatomy, ischemic relevance, and expected procedural benefit when selecting and planning revascularization (27-29). Within this framework, CCTA-guided PCI is likely to be most useful in selected patients in whom preprocedural information can meaningfully alter procedural strategy, particularly those with ostial, left main or bifurcation disease, severe calcification, CTO, long diffuse disease, or multivessel disease (8,19-23). In these complex settings, such multidimensional information may help define procedural anatomy, anticipate technical challenges, and refine treatment strategy before catheterization. Related physiology studies have shown that disease distribution and anticipated post-PCI physiology may inform procedural planning, supporting the broader concept of physiology-informed intervention, although these findings do not directly establish the efficacy of CCTA-guided PCI (30-33). Although CCTA-guided PCI is not yet routinely integrated into intraprocedural angiographic workflows, CCTA-angiography fusion may translate preprocedural three-dimensional anatomical and functional information directly into the catheterization laboratory, enabling interactive, patient-specific guidance beyond the operator’s mental integration of preprocedural imaging (34).

CT-based virtual planning extends this concept by allowing post-PCI physiology to be simulated from preprocedural CCTA, supporting the potential role of virtual stenting and procedural simulation (35). Such approaches should complement, rather than replace, invasive angiography, intravascular imaging, and invasive physiology when clinically indicated, particularly in complex PCI (36). Prospective evidence for CCTA-guided PCI remains limited but is expanding. The P4 randomized trial is designed to compare CCTA-guided with intravascular ultrasound (IVUS)-guided PCI with respect to clinical outcomes (37). The CT-PLAN PCI trial is designed to evaluate whether CCTA-guided planning can improve procedural efficiency compared with routine PCI (38), whereas the OPTIMAL trial is examining a CCTA-guided calcium-modification strategy versus an IVUS-guided strategy in patients with calcified coronary disease (39). The NAVIGATE-PCI registry is prospectively assessing real-world implementation, procedural planning, resource utilization, and in-hospital outcomes associated with CT-derived guidance before stenting (40). These studies are designed to evaluate procedural efficacy, workflow, and clinical outcomes, whereas the present survey addresses a different but complementary question: how CCTA-guided PCI is currently implemented, what information clinicians consider useful, which tools are available, and what barriers limit broader adoption.

The present survey also demonstrates substantial heterogeneity in implementation across regions, hospital tiers, and professional groups among participating institutions. East Chinese mainland accounted for 36/109 questionnaires (33.0%), several regional strata were small, and 86/108 unique participating institutions (79.6%) were tertiary hospitals. Regional and hospital-tier analyses showed marked differences in PCI, CCTA, and CT-FFR activity, but the survey did not collect population, economic, reimbursement, or other health-system variables that could explain these differences. In addition, the open, voluntary-response design may have preferentially attracted institutions with greater cardiovascular imaging or interventional activity. Interdepartmental differences were also evident: radiology respondents more often emphasized left main and bifurcation anatomy, side branches, downstream myocardial characteristics, and inflammatory features, whereas cardiology respondents assigned relatively greater importance to calcification severity and CCTA-angiography fusion. These complementary perspectives, together with reported shortages of trained personnel and workflow barriers, suggest that the principal implementation gap is not simply access to CCTA, but the lack of a shared and consistently applied PCI-oriented framework for translating CCTA findings into procedural decisions.

The next stage should focus on converting this diagnostic foundation into a standardized and sustainable clinical pathway. First, CCTA acquisition and reconstruction should meet PCI-planning quality standards, including explicit handling of motion, calcification, stents, small vessels, segmentation failure, and CT-FFR rejection. Second, reporting should include actionable PCI-oriented elements such as target segment, lesion length, reference vessel size, calcification, plaque characteristics, bifurcation anatomy, landing zones, and functional results when appropriate. Third, multidisciplinary collaboration between interventional cardiology and cardiac imaging should be strengthened so that complementary clinical, procedural, anatomical, plaque-related, and functional information can be integrated into individualized PCI planning, rather than allowing the workflow to be centered on either discipline alone. Fourth, advanced tools such as CT-FFR, CT myocardial perfusion, quantitative plaque analysis, CCTA-angiography fusion, and virtual planning should be prioritized when they are likely to change management, particularly in complex PCI. Implementation should also be phased according to institutional capacity. High-capacity centers may progressively incorporate these tools into multidisciplinary workflows, whereas resource-limited centers may initially prioritize standardized acquisition, quality control, structured reporting, referral pathways, and focused training. Finally, training programs, validated software, sustainable billing and reimbursement pathways, structured reporting templates, and prospective procedural, clinical, and cost-effectiveness studies are needed to support broader implementation. The goal is to integrate high-quality CCTA-derived information before PCI into multidisciplinary decision-making to improve preparation, reduce uncertainty, and support more individualized coronary revascularization.

Limitations

Several limitations should be acknowledged. First, this open, voluntary-response survey lacked a predefined national sampling frame; therefore, a formal response rate could not be calculated, and self-selection, tertiary-hospital predominance, and uneven regional representation may limit generalizability. The findings should thus be interpreted as practice patterns among participating institutions rather than population-level estimates for the Chinese mainland. Second, cardiology and radiology responses were not systematically paired, precluding within-institution comparisons. Third, annual PCI, CCTA, and CT-FFR volumes for 2016–2025 were retrospectively reported and not independently verified. Fourth, patient-level linkage between CCTA and subsequent PCI was not collected; reported CT use therefore reflects departmental practice rather than a verified patient-level rate of CCTA-guided PCI and cannot assess procedural efficacy or clinical outcomes. Fifth, several regional and hospital-tier subgroups were small, and socioeconomic or health-system variables were unavailable, limiting interpretation of observed heterogeneity. Finally, advanced CT technologies continue to evolve rapidly. Future studies should incorporate defined sampling frames, matched multidisciplinary data, patient-level CCTA-to-PCI linkage, and prospective evaluation of procedural, clinical, and cost-effectiveness outcomes.

Conclusions

Among participating institutions in the Chinese mainland, expanding PCI and CCTA capacity provides a growing foundation for CCTA-guided PCI, but its translation into routine procedural planning remains incomplete and heterogeneous. Current use is dominated by anatomical and quantitative assessment, while functional and advanced procedural-planning applications remain less widely integrated. CT is perceived to be particularly valuable in complex PCI. Standardized PCI-oriented workflows, multidisciplinary collaboration, sustainable reimbursement, and phased implementation according to institutional capacity may facilitate broader clinical integration.

Acknowledgments

The authors take full responsibility for the accuracy and integrity of the final manuscript. The authors thank all participating centers, cardiologists, radiologists, and survey contacts for their contributions to questionnaire completion and survey dissemination.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://rx.amegroups.com/article/view/10.21037/rx-26-0072/rc

Data Sharing Statement: Available at https://rx.amegroups.com/article/view/10.21037/rx-26-0072/dss

Peer Review File: Available at https://rx.amegroups.com/article/view/10.21037/rx-26-0072/prf

Funding: This work was supported by the National Natural Science Foundation of China Youth Program (grant No. 82502478) and the National Natural Science Foundation of China (Nos. 82522047, 82370513).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://rx.amegroups.com/article/view/10.21037/rx-26-0072/coif). N.D. serves as the Editor-in-Chief of Radiology-X. Junbo Ge serves as an unpaid Honorary Editor-in-Chief of Radiology-X from February 2026 to January 2028. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Ethics Committee of Fuwai Hospital (approval No. 2026-3087). This questionnaire-based survey evaluated institutional practice patterns and physicians’ perceptions and did not involve patient intervention, patient-level clinical data, biological specimens, or identifiable patient information. The requirement for written informed consent was waived by the ethics committee. Survey participation was voluntary, and the results were analyzed at the aggregate level.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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