Radiomics of Pericoronary Adipose Tissue on Coronary CT Angiography to Predict Clinical Outcomes: A Systematic Review

Background: Pericoronary adipose tissue (PCAT) radiomics on coronary computed tomography angiography (CCTA) may capture inflammatory and structural information beyond conventional attenuation measures. We assessed whether PCAT radiomics predicts future coronary events or quantifies plaque progression. Methods: PubMed/MEDLINE, Embase, and Web of Science were searched from inception to 29 August 2025. Eligible studies included adults undergoing CCTA with quantitative PCAT, or anatomically equivalent coronary perivascular adipose tissue (PVAT), radiomics, and longitudinal clinical or serial-CCTA outcomes. Findings were synthesised narratively because no common estimand supported meta-analysis. Methodological quality was assessed using QUADAS-2 and the Radiomics Quality Score (RQS). Results: Eleven full-text studies, representing at least 6307 participants were included; one study also analysed 127 plaques in 97 patients, and one reported a separate 202-person model-development sample whose overlap with its 1575-person cohort evaluation was not quantified. Eight studies evaluated coronary clinical events, and three evaluated plaque progression. Seven clinical-event studies reported better discrimination for radiomics-based or integrated models than at least one conventional comparator, although calibration and clinical-utility reporting were inconsistent. Two studies included clearly independent external validation. QUADAS-2 identified high patient-selection risk in 4/11 studies; RQSs ranged from 10/36 to 15/36 (mean: 12.5/36). Conclusions: PCAT radiomics shows preliminary prognostic potential, but confidence in the evidence is low because of retrospective designs, heterogeneous outcomes and workflows, restricted geographic sampling, and limited independent external validation. Current evidence is insufficient for routine clinical decision-making. Prospective multicentre validation with standardised acquisition, analysis, reporting, and clinically consistent endpoints is required.