# First Clinical Use of a Novel AI-Based Imaging Tool to Enhance CTO PCI Planning

## TL;DR

A new AI tool called STEP improves imaging for complex heart procedures by revealing hidden pathways and collaterals, helping doctors plan better and succeed in challenging cases.

## Contribution

This is the first clinical application of AI-based spatiotemporal enhancement processing (STEP) to guide chronic total occlusion PCI.

## Key findings

- STEP software revealed a microchannel and epicardial collateral not visible on standard angiograms.
- The AI-enhanced imaging enabled a successful parallel wiring strategy, avoiding a retrograde approach.
- AI-based image enhancement provided actionable insights that improved procedural planning and success.

## Abstract

Chronic total occlusion (CTO) interventions are frequently limited by incomplete angiographic information. We report the use of a novel artificial intelligence (AI)–based spatiotemporal enhancement processing (STEP) software (AngioWave Imaging), which identified both an antegrade crossing pathway and an epicardial collateral, neither of which was apparent on the unprocessed angiogram. These insights guided the procedural strategy, including the decision to attempt parallel wiring, thereby contributing to procedural success.

A 59-year-old man presented with non–ST-segment elevation myocardial infarction, with the diagnostic angiogram revealing a culprit left anterior descending artery lesion and a circumflex CTO. After undergoing culprit vessel percutaneous coronary intervention (PCI), he was referred for CTO PCI. Angiographic assessment of the circumflex CTO was limited. Enhancement of the angiogram was performed using the STEP software, which revealed a microchannel and an epicardial collateral, both not evident on the unprocessed angiogram. On the basis of this information, we used a successful parallel wiring strategy.

This case report presents the first clinical use of AI-based STEP image enhancement in PCI. Conventional angiography may fail to adequately delineate lesion architecture and collateral circulation, both of which are critical for CTO case planning. In this patient, AI-based enhancement identified an antegrade microchannel that enabled parallel wiring and avoided premature conversion to a retrograde strategy in a vessel not suitable for antegrade dissection and re-entry. STEP-enhanced angiograms provided actionable procedural guidance beyond standard imaging, underscoring their potential role in complex interventions.

Understand how STEP-based image-processing platforms can augment strategy selection in CTO PCI and reduce procedural time, radiation, and contrast exposure.