San Diego—A planning strategy utilizing coronary CT angiography (CCTA) prior to PCI resulted in similar clinical outcomes at 12 months when compared with an intravascular ultrasound (IVUS)-guided approach, according to results of a new study.
The Precise Procedural PCI Plan (P4) study, which was presented today during the late-breaking clinical trial session at TCT 2026 and published simultaneously in the New England Journal of Medicine, also showed that the CCTA-based strategy was associated with shorter procedural times compared with IVUS-guided PCI.
Lead investigator Carlos Collet, MD, PhD (Cardiovascular Research Foundation, New York, NY), said their data supports the CCTA-based pathway for PCI planning guidance in selected patients. This strategy, he said, gives operators a better sense of what they’ll encounter when they step into the catheterization laboratory, just like with structural interventions.
“We don’t plan the [PCI] procedures,” he said during a TCT press conference. “We basically go into the cath lab, make a couple of injections, and try to decide what to do on the fly. This is a core element of the study because it addresses how we can prepare better for a procedure. We incorporate structured planning in the design, which would lead to better preparation before [operators] do the procedure.”
The CCTA-based strategy included an assessment of coronary anatomy, lesion and plaque characteristics, calcium burden, myocardial mass at risk, and coronary physiology. Based on the data, operators were provided direction on lesion preparation, necessary stent length and diameter, proximal and distal landing zones, and optimal angiographic projections.
“Coronary CT has evolved tremendously over the years and today it is capable to offer this type of information,” said Collet.
Emmanouil Brilakis, MD, PhD (Minneapolis Heart Institute Foundation, MN), the discussant following the presentation, called P4 a “landmark” trial and praised the meticulous methodology. While the study has limitations, including the relatively straightforward patient population, he believes the clinical evidence supports CCTA-guided PCI. Before the technology gets into the mainstream, though, “we need to learn how to actually use the CT, how to look at the CT images, and how to implement them for our planning practices,” said Brilakis.
B. Hadley Wilson, MD (Wake Forest School of Medicine, Winston-Salem, NC), past president of the American College of Cardiology who wasn’t involved in the study, said P4 is potentially a “game-changing trial.” Like Brilakis, though, Wilson said that “we’re not there yet” with this strategy.
“Some places don’t have the imaging, but there are also many major centers where we do coronary CT imaging ahead of PCI, but not to the level that they’re showing in P4,” Wilson told Cardiology Now News. “We don’t have this type of precise planning where it’s pointing out: the lesion is this long, it’s got this much calcium, and you’re going to need this size stent.”
While CCTA-guided PCI likely represents the future, Wilson said there are still a number of questions, including around affordability.
The P4 Randomized Trial
In the P4 randomized, non-inferiority trial, investigators randomized 1,105 patients (median age 65 years; 78.3% men) to CCTA-guided or IVUS-guided PCI at 23 international sites.
The majority of patients had stable ischemic heart disease (approximately 98%) and underwent CCTA as part of routine clinical care before trial enrollment. Patients were eligible for randomization if they had at least one epicardial lesion with CT-derived fractional flow reserve of 0.80 or less, which indicates a physiologically significant lesion, and a diameter stenosis greater than 70%.
Target-vessel failure, a composite that included death from cardiac causes, target-vessel MI, or ischemia-driven target-vessel revascularization, occurred in 4.1% in patients randomized to CCTA-guided PCI compared with 4.6% in those randomized to IVUS-guided PCI (risk difference -0.42 percentage points; 95% CI -2.82 to 1.99; P < 0.001 for noninferiority). There was no difference in any of the individual components of the primary endpoint.
The median duration of CCTA-guided PCI was 46 minutes compared with 63 minutes in those who were treated using IVUS. Contrast volume and radiation exposure were slightly lower with the CCTA-based strategy. However, Wilson and Brilakis both cautioned that the study investigators did not account for contrast volume or radiation during the preplanning CCTA.
To Cardiology News Now, Collet explained that IVUS was mandated before and after the procedure in the IVUS-guided PCI arm and prohibited in the CCTA group except for bailout use. With the CCTA-guided strategy, “once you place the stent, the CT can’t help you anymore because it was acquired before [the PCI],” he said. However, 3D CCTA reconstructions were synchronized with the angiography. “In the CT arm, we mandated something called stent enhancement, which are tools that allow us to understand the stent expansion with the use of angiography,” he said.
In the US, CCTA is infrequently performed prior to PCI, although the numbers are increasing, said Collet. In P4, patients were randomized if eligible based on the CCTA performed outside the study.
“That’s important because that integrates real-world practice in terms of CT acquisition,” said Collet.
P5 Trial Underway
Anatomical complexity was “relatively low,” said Collet, noting that the median SYNTAX score ranged between 8 and 9. However, subgroup analyses suggested that the most complex patients gained the most from the CCTA-based strategy, which led investigators to launch P5, a study in patients with complex disease that has begun enrollment.
Collet said that six software programs were required to prepare the information for interventional cardiologists, but sponsors have since developed integrated software to make the CCTA-based strategy feasible in clinical practice. Investigators have not yet performed a formal cost-effectiveness analysis, but Collet noted that if procedures are reduced by 17 minutes with CCTA, “that means you can do a couple more [PCIs] a day.”
Margaret McEntegart, MD, PhD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), another of the TCT panelists, stressed that the detailed information available with this CCTA-based strategy must be available through an “intuitive” and “simplified” interface given how busy operators are daily.
Rasha Al-Lamee, MD, PhD (Imperial College London, UK), one of the TCT panelists, said the vast majority of patients in the UK come to the cath lab after undergoing CCTA, but operators do not use the information to plan the procedure. The reason is that CT has been the domain of radiology, with interventional cardiologists usually just reading the report.
Wilson agreed, telling Cardiology News Now that cardiologists will need to become better acquainted with reading and interpreting CCTA results. Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), the session moderator, said that if cardiologists don’t learn how to read and interpret CT, “I think you’re going to become obsolete.”
Source:
Collet C, Mizukami T, Bouisset F, et al. Coronary CT versus intravascular ultrasound guidance for PCI. N Engl J Med. Published online November 1, 2026.
Disclosures:
Collet reports grant support/research contracts and/or consulting fees/honoraria from Abbott, Boston Scientific, Cathworks, GE Healthcare, Medyria, Shockwave Medical, Siemens Healthineers, and Insight Lifetech. He reports equity and/or stock options in Powerful Medical, CathFlow, and Medyria.
Brilakis reports consulting fees/honoraria from Abbott Vascular, Cordis, Biotronik, Boston Scientific, GE Healthcare, Medtronic, Teleflex, IMDS, Terumo Medical. He reports grant/research support from Boston Scientific, GE Healthcare, and Angiowave and equity/stock from MHI Ventures, Cleerly Health, Stallion Medical, LifeLens Technologies, and TrueVue.
McEntegart reports consulting fees/honoraria from Abbott, Biosense Webster, Boston Scientific, Shockwave, Medtronic, and Teleflex.
Al-Lamee reports consulting fees/honoraria from Philips Volcano, Menarini, Abbott, Medtronic, Servier, and AstraZeneca. She serves on advisory boards for Janssen Pharmaceuticals, Cathworks, and Shockwave Medical.
Kirtane reports grant support/research contracts from Abbott, Medtronic, Boston Scientific, Amgen, Cathworks, Siemens, Philips, Recor Medical, Spectranetics, Chiesi, Concept Medical, Neurotronik, Biotronik, Magenta, Canon, SoniVie, Shockwave Medical, Abiomed, Teleflex, and Supira. He reports consulting for SoniVie.
Wilson reports no conflicts of interest.