Non-invasive and invasive imaging for guiding PCI of chronic total occlusions

INTRODUCTION: Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains technically challenging, with lower technical success than non-CTO PCI. Coronary computed tomography angiography (CCTA) and intravascular ultrasound (IVUS) may improve procedural and stent-related outcomes by supporting procedural planning, lesion crossing, and stent optimization. AREAS COVERED: A literature search of PubMed, Google scholar, identified randomized trials, registries, observational studies, meta-analyses, and consensus documents on CCTA and IVUS in CTO PCI. CCTA enables three-dimensional assessment of cap morphology, occlusion length, tortuosity, calcification, and distal vessel quality, refining complexity assessment and strategy selection. IVUS provides real-time guidance for proximal cap identification, guidewire position, reentry techniques, vessel sizing, and stent optimization. Artificial intelligence and image co-registration are also discussed. EXPERT OPINION: CCTA and IVUS provide complementary information across the stages of CTO PCI. Selective preprocedural CCTA may be most valuable in anatomically complex lesions, whereas IVUS supports lesion crossing and should be strongly considered for stent optimization. Wider adoption will depend on workflow integration, operator training, automated image analysis, and prospective validation of imaging-guided strategies.