Coronary computed tomography angiography (CCTA) is increasingly recognized as a comprehensive tool for planning percutaneous coronary intervention (PCI). By integrating plaque morphology, calcium burden, and CT-derived coronary physiology, CCTA enables non-invasive assessment of lesion complexity and supports precision-guided revascularization. This narrative review synthesizes current evidence on CT-guided PCI from original studies, registries, expert consensus documents, and international guideline recommendations. The literature was identified through PubMed, Embase, and Google Scholar, focusing on CCTA-based plaque characterization, calcium assessment, bifurcation and ostial lesions, chronic total occlusions (CTO), FFR-CT, virtual PCI simulation, and fusion imaging. Particular attention was given to contemporary investigations such as SYNTAX III, P3, and the ongoing P4 trial. CCTA reliably characterizes stenosis severity, plaque distribution, and calcification, demonstrating strong concordance with intravascular imaging. CT-based measurements support accurate stent sizing, prediction of calcium modification requirements, and identification of high-risk features in bifurcation and ostial disease. In CTO PCI, CCTA enhances visualization of proximal cap morphology, occlusion length, tortuosity, and distal vessel quality, outperforming angiographic scoring systems. CT-derived physiology and virtual PCI planning improve lesion selection and allow prediction of post-PCI hemodynamics. Emerging technologies—including photon-counting CT, artificial intelligence-assisted plaque analysis, and CT–fluoroscopy fusion—further expand the applicability of CT-guided PCI. The ongoing P4 trial is expected to provide definitive validation of CT-guided PCI and may support its incorporation into routine clinical workflows.

Radial wall strain (RWS) is an angiography-derived biomechanical index that quantifies plaque deformability from routine coronary angiography, offering a novel approach to assess plaque vulnerability beyond conventional anatomical and physiological parameters. This narrative review synthesizes current evidence on the pathophysiological basis, clinical applications, and prognostic implications of RWS in coronary artery disease. Recent studies have demonstrated that elevated RWS values are associated with established markers of plaque vulnerability, including thin-cap fibroatheromas and large lipid cores, as well as increased risk of major adverse cardiovascular events. Furthermore, RWS has emerged as a promising tool for identifying vulnerable plaques in non-flow-limiting lesions and predicting in-stent restenosis, demonstrating incremental prognostic value when combined with angiography-derived physiological indices such as the quantitative flow ratio. By integrating biomechanical assessment with conventional physiological and morphological characterization, RWS may enhance risk stratification and guide clinical decision-making in percutaneous coronary intervention. While current evidence is encouraging, prospective randomized trials are needed to validate RWS-guided management strategies and establish optimal cutoff values for clinical implementation.