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Saudi Journal of Radiology

Volume 5, 2026 · Issue 1st Issue · Open Access · Double-blind Peer-review

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Original Research Article

Photon-Counting Computed Tomography in Coronary Imaging: A Scoping Review of Current Evidence

Abubakr Bajaber1, Zainab Alabdulmuhsin2, Alwaleed Alamro3, Abdulaziz Almeraiheel4, Bahiyyah Bahkali5, Shaden Alhenaki3, Taif Aljaber6, Aya ALhabashi7, Sarah Binsultan8 & Awadia Gareeballah9

1 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia

2 King Faisal University

3 Qassim university

Published: 05 May 2026

https://doi.org/10.55038/thr2d933
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Abstract
Photon-counting computed tomography (PCCT) represents an emerging imaging technology with potential advantages for coronary artery assessment. This scoping review aimed to characterize the current body of literature on PCCT for coronary imaging and to identify existing gaps and future research priorities. A systematic scoping review was conducted in accordance with the Arksey and O’Malley framework and PRISMA guidelines. Peer-reviewed studies published in English since 2012 were retrieved from multiple electronic databases using predefined keyword combinations. Study selection and data extraction were independently performed by multiple reviewers, with discrepancies resolved through consensus. Thirty-one studies met the inclusion criteria. Of these, 40% involved human subjects, encompassing a total of 747 participants. Early investigations conducted between 2017 and 2021 were predominantly preclinical, whereas studies published from 2022 onward demonstrated a clear transition toward clinical application. Most clinical studies focused on coronary artery disease assessment (73.1%), followed by coronary stent evaluation (15.4%), or both (11.5%). Sample sizes in clinical studies were relatively small, ranging from 3 to 197 participants (median 61.8), and primarily included patients with known or suspected coronary artery disease. The majority of publications originated from the United States and Europe, often involving multinational collaborations, while data from other regions remained limited. Most studies compared PCCT with conventional computed tomography, with few direct comparisons to alternative imaging modalities such as magnetic resonance imaging. Overall, the literature reflects a maturing field transitioning from technical validation to early clinical implementation. However, limitations including small sample sizes, restricted patient diversity, geographic concentration, and limited multimodality comparisons persist. Addressing these gaps through large-scale, multicenter studies, standardized methodologies, and broader international collaboration will be essential to fully define the clinical role of PCCT in coronary imaging.
KeywordsAtherosclerosis ImagingCardiovascularCoronary Artery DiseaseCoronary ImagingMyocardial ImagingPhoton-Counting CTScoping Review

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References

  1. Friede A, O’Carroll PW, Thralls RB, Reid JA. CDC WONDER on the Web. Proc Conf Am Med Inform Assoc AMIA Fall Symp. 1996; 408–412.
  2. Roth GA, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392: 1736–1788. doi:10.1016/S0140-6736(18)32203-7
  3. Willemink MJ, Persson M, Pourmorteza A, Pelc NJ, Fleischmann D. Photon-counting CT: Technical Principles and Clinical Prospects. Radiology. 2018;289: 293–312. doi:10.1148/radiol.2018172656
  4. Blankstein R, Shturman LD, Rogers IS, Rocha-Filho JA, Okada DR, Sarwar A, et al. Adenosine-Induced Stress Myocardial Perfusion Imaging Using Dual-Source Cardiac Computed Tomography. J Am Coll Cardiol. 2009;54: 1072–1084. doi:10.1016/j.jacc.2009.06.014
  5. Schuijf JD, Wijns W, Jukema JW, Atsma DE, De Roos A, Lamb HJ, et al. Relationship Between Noninvasive Coronary Angiography With Multi-Slice Computed Tomography and Myocardial Perfusion Imaging. J Am Coll Cardiol. 2006;48: 2508–2514. doi:10.1016/j.jacc.2006.05.080
  6. Ghoshhajra BB, Engel L-C, Major GP, Goehler A, Techasith T, Verdini D, et al. Evolution of Coronary Computed Tomography Radiation Dose Reduction at a Tertiary Referral Center. Am J Med. 2012;125: 764–772. doi:10.1016/j.amjmed.2011.10.036
  7. Taguchi K, Iwanczyk JS. Vision 20/20: Single photon counting x‐ray detectors in medical imaging. Med Phys. 2013;40: 100901. doi:10.1118/1.4820371
  8. Meloni A, Cademartiri F, Positano V, Celi S, Berti S, Clemente A, et al. Cardiovascular Applications of Photon-Counting CT Technology: A Revolutionary New Diagnostic Step. J Cardiovasc Dev Dis. 2023;10: 363. doi:10.3390/jcdd10090363
  9. Flohr T, Schmidt B, Ulzheimer S, Alkadhi H. Cardiac imaging with photon counting CT. Br J Radiol. 2023;96: 20230407. doi:10.1259/bjr.20230407
  10. Si-Mohamed SA, Boccalini S, Lacombe H, Diaw A, Varasteh M, Rodesch P-A, et al. Coronary CT Angiography with Photon-counting CT: First-In-Human Results. Radiology. 2022;303. doi:10.1148/radiol.211780
  11. Braun FM, Risch F, Decker JA, Woźnicki P, Bette S, Becker J, et al. Image Characteristics of Virtual Non-Contrast Series Derived from Photon-Counting Detector Coronary CT Angiography—Prerequisites for and Feasibility of Calcium Quantification. Diagnostics. 2023;13: 3402. doi:10.3390/diagnostics13223402
  12. Donuru A, Araki T, Dako F, Dave JK, Perez RP, Xu D, et al. Photon-counting detector CT allows significant reduction in radiation dose while maintaining image quality and noise on non-contrast chest CT. Eur J Radiol Open. 2023;11: 100538. doi:10.1016/j.ejro.2023.100538
  13. Rajendran K, Petersilka M, Henning A, Shanblatt ER, Schmidt B, Flohr TG, et al. First Clinical Photon-counting Detector CT System: Technical Evaluation. Radiology. 2022;303: 130–138. doi:10.1148/radiol.212579
  14. Halfmann MC, Bockius S, Emrich T, Hell M, Schoepf UJ, Laux GS, et al. Ultrahigh-Spatial-Resolution Photon-counting Detector CT Angiography of Coronary Artery Disease for Stenosis Assessment. Radiology. 2024;310: e231956. doi:10.1148/radiol.231956
  15. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8: 19–32. doi:10.1080/1364557032000119616
  16. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18: 143. doi:10.1186/s12874-018-0611-x
  17. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169: 467–473. doi:10.7326/M18-0850
  18. Peters MDJ, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18: 2119–2126. doi:10.11124/JBIES-20-00167
  19. Mannil M, Hickethier T, Von Spiczak J, Baer M, Henning A, Hertel M, et al. Photon-Counting CT: High-Resolution Imaging of Coronary Stents. Invest Radiol. 2018;53: 143–149. doi:10.1097/RLI.0000000000000420
  20. Symons R, Cork TE, Lakshmanan MN, Evers R, Davies-Venn C, Rice KA, et al. Dual-contrast agent photon-counting computed tomography of the heart: initial experience. Int J Cardiovasc Imaging. 2017;33: 1253–1261. doi:10.1007/s10554-017-1104-4
  21. Symons R, Sandfort V, Mallek M, Ulzheimer S, Pourmorteza A. Coronary artery calcium scoring with photon-counting CT: first in vivo human experience. Int J Cardiovasc Imaging. 2019;35: 733–739. doi:10.1007/s10554-018-1499-6
  22. Bratke G, Hickethier T, Bar-Ness D, Bunck AC, Maintz D, Pahn G, et al. Spectral Photon-Counting Computed Tomography for Coronary Stent Imaging. Invest Radiol. 2020;55: 61–67. doi:10.1097/RLI.0000000000000610
  23. Juntunen MAK, Sepponen P, Korhonen K, Pohjanen V-M, Ketola J, Kotiaho A, et al. Interior photon counting computed tomography for quantification of coronary artery calcium: pre-clinical phantom study. Biomed Phys Eng Express. 2020;6: 055011. doi:10.1088/2057-1976/aba133
  24. Sandfort V, Persson M, Pourmorteza A, Noël PB, Fleischmann D, Willemink MJ. Spectral photon-counting CT in cardiovascular imaging. J Cardiovasc Comput Tomogr. 2021;15: 218–225. doi:10.1016/j.jcct.2020.12.005
  25. Rajagopal JR, Farhadi F, Richards T, Nikpanah M, Sahbaee P, Shanbhag SM, et al. Evaluation of Coronary Plaques and Stents with Conventional and Photon-counting CT. Radiol Cardiothorac Imaging. 2021;3: e210102. doi:10.1148/ryct.2021210102
  26. Van Der Werf NR, Van Gent M, Booij R, Bos D, Van Der Lugt A, Budde RPJ, et al. Dose Reduction in Coronary Artery Calcium Scoring Using Mono-Energetic Images from Reduced Tube Voltage Dual-Source Photon-Counting CT Data. Diagnostics. 2021;11: 2192. doi:10.3390/diagnostics11122192
  27. Willemink MJ, Varga-Szemes A, Schoepf UJ, Codari M, Nieman K, Fleischmann D, et al. Emerging methods for the characterization of ischemic heart disease. Eur Radiol Exp. 2021;5: 12. doi:10.1186/s41747-021-00207-3
  28. Soschynski M, Hagen F, Baumann S, Hagar MT, Weiss J, Krauss T, et al. High Temporal Resolution Dual-Source Photon-Counting CT for Coronary Artery Disease. J Clin Med. 2022;11: 6003. doi:10.3390/jcm11206003
  29. Ayx I, Tharmaseelan H, Hertel A, Nörenberg D, Overhoff D, Rotkopf LT, et al. Myocardial Radiomics Texture Features Associated with Increased Coronary Calcium Score. Diagnostics. 2022;12: 1663. doi:10.3390/diagnostics12071663
  30. Van Der Werf NR, Rodesch PA, Si-Mohamed S, Van Hamersvelt RW, Greuter MJW, Leiner T, et al. Improved coronary calcium detection and quantification with low-dose photon-counting CT. Eur Radiol. 2022;32: 3447–3457. doi:10.1007/s00330-021-08421-8
  31. Van Der Werf NR, Si-Mohamed S, Rodesch PA, Van Hamersvelt RW, Greuter MJW, Boccalini S, et al. Coronary calcium scoring potential of large field-of-view spectral photon-counting CT: a phantom study. Eur Radiol. 2022;32: 152–162. doi:10.1007/s00330-021-08152-w
  32. Mergen V, Sartoretti T, Baer-Beck M, Schmidt B, Petersilka M, Wildberger JE, et al. Ultra-High-Resolution Coronary CT Angiography With Photon-Counting Detector CT: Feasibility and Image Characterization. Invest Radiol. 2022;57: 780–788. doi:10.1097/RLI.0000000000000897
  33. Boccalini S, Si-Mohamed SA, Lacombe H, Diaw A, Varasteh M, Rodesch P-A, et al. First In-Human Results of Computed Tomography Angiography for Coronary Stent Assessment With a Spectral Photon Counting Computed Tomography. Invest Radiol. 2022;57: 212–221. doi:10.1097/RLI.000
  34. 0000000000835
  35. Van Der Werf NR, Greuter MJW, Booij R, Van Der Lugt A, Budde RPJ, Van Straten M. Coronary calcium scores on dual-source photon-counting computed tomography: an adapted Agatston methodology aimed at radiation dose reduction. Eur Radiol. 2022;32: 5201–5209. doi:10.1007/s00330-022-08642-5
  36. Van Der Werf NR, Booij R, Greuter MJW, Bos D, Van Der Lugt A, Budde RPJ, et al. Reproducibility of coronary artery calcium quantification on dual-source CT and dual-source photon-counting CT: a dynamic phantom study. Int J Cardiovasc Imaging. 2022;38: 1613–1619. doi:10.1007/s10554-022-02540-z
  37. Meloni A, Cademartiri F, Positano V, Celi S, Berti S, Clemente A, et al. Cardiovascular Applications of Photon-Counting CT Technology: A Revolutionary New Diagnostic Step. J Cardiovasc Dev Dis. 2023;10: 363. doi:10.3390/jcdd10090363
  38. Stein T, Taron J, Verloh N, Doppler M, Rau A, Hagar MT, et al. Photon-counting computed tomography of coronary and peripheral artery stents: a phantom study. Sci Rep. 2023;13: 14806. doi:10.1038/s41598-023-41854-3
  39. Cademartiri F, Meloni A, Pistoia L, Degiorgi G, Clemente A, Gori CD, et al. Dual-Source Photon-Counting Computed Tomography—Part I: Clinical Overview of Cardiac CT and Coronary CT Angiography Applications. J Clin Med. 2023;12: 3627. doi:10.3390/jcm12113627
  40. Vecsey-Nagy M, Varga-Szemes A, Emrich T, Zsarnoczay E, Nagy N, Fink N, et al. Calcium scoring on coronary computed angiography tomography with photon-counting detector technology: Predictors of performance. J Cardiovasc Comput Tomogr. 2023;17: 328–335. doi:10.1016/j.jcct.2023.08.004
  41. Rotkopf LT, Froelich MF, Riffel P, Ziener CH, Reid C, Schlemmer H-P, et al. Influence of heart rate and heart rate variability on the feasibility of ultra-fast, high-pitch coronary photon-counting computed tomography angiography. Int J Cardiovasc Imaging. 2023;39: 1065–1073. doi:10.1007/s10554-023-02808-y
  42. Greffier J, Si-Mohamed SA, Lacombe H, Labour J, Djabli D, Boccalini S, et al. Virtual monochromatic images for coronary artery imaging with a spectral photon-counting CT in comparison to dual-layer CT systems: a phantom and a preliminary human study. Eur Radiol. 2023;33: 5476–5488. doi:10.1007/s00330-023-09529-9
  43. Dobrolinska MM, Van Der Werf NR, Van Der Bie J, De Groen J, Dijkshoorn M, Booij R, et al. Radiation dose optimization for photon-counting CT coronary artery calcium scoring for different patient sizes: a dynamic phantom study. Eur Radiol. 2023;33: 4668–4675. doi:10.1007/s00330-023-09434-1
  44. Hagar MT, Soschynski M, Saffar R, Rau A, Taron J, Weiss J, et al. Accuracy of Ultrahigh-Resolution Photon-counting CT for Detecting Coronary Artery Disease in a High-Risk Population. Radiology. 2023;307: e223305. doi:10.1148/radiol.223305
  45. Rajagopal JR, Farhadi F, Nikpanah M, Sahbaee P, Saboury B, Pritchard WF, et al. Impact of the confluence of cardiac motion and high spatial resolution on performance of ECG-gated imaging with an investigational photon-counting CT system: A phantom study. Phys Med. 2023;114: 102683. doi:10.1016/j.ejmp.2023.102683
  46. Van Der Bie J, Bos D, Dijkshoorn ML, Booij R, Budde RPJ, Van Straten M. Thin slice photon‐counting CT coronary angiography compared to conventional CT: Objective image quality and clinical radiation dose assessment. Med Phys. 2024;51: 2924–2932. doi:10.1002/mp.16992
  47. Vattay B, Boussoussou M, Vecsey-Nagy M, Kolossváry M, Juhász D, Kerkovits N, et al. Qualitative and quantitative image quality of coronary CT angiography using photon-counting computed tomography: Standard and Ultra-high resolution protocols. Eur J Radiol. 2024;175: 111426. doi:10.1016/j.ejrad.2024.111426
  48. Hagen F, Soschynski M, Weis M, Hagar MT, Krumm P, Ayx I, et al. Photon-counting computed tomography – clinical application in oncological, cardiovascular, and pediatric radiology. RöFo - Fortschritte Auf Dem Geb Röntgenstrahlen Bildgeb Verfahr. 2024;196: 25–35. doi:10.1055/a-2119-5802
  49. Mundt P, Hertel A, Tharmaseelan H, Nörenberg D, Papavassiliu T, Schoenberg SO, et al. Analysis of Epicardial Adipose Tissue Texture in Relation to Coronary Artery Calcification in PCCT: The EAT Signature! Diagnostics. 2024;14: 277. doi:10.3390/diagnostics14030277
  50. Zhou S, Liu P, Dong H, Li J, Xu Z, Schmidt B, et al. Performance of calcium quantifications on low-dose photon-counting detector CT with high-pitch: A phantom study. Heliyon. 2024;10: e32819. doi:10.1016/j.heliyon.2024.e32819