Complex Angioplasty — CTO

Usually not, and it is the question almost everyone asks. Because the block came on slowly, your body had time to grow tiny natural detours — collaterals — from the other arteries, and those kept the muscle alive. That is why you are breathless on the stairs rather than having a heart attack. The muscle is generally still there and still working, just living on a limited supply, and restoring the full supply is what relieves the symptom. What we check carefully before offering the procedure is exactly this: that the muscle beyond the block is alive and short of blood, not scarred.

No — and that is genuinely good news. A chronic total occlusion is the opposite of a heart attack: it is old and stable, and it has been that way for months. Nothing about it needs to be done today. It means we have time to plan it properly — to look at both arteries, sometimes get a CT scan first, and choose the safest route — rather than rushing.

I have to be honest here, because it is the most important thing to understand. Opening a CTO is done to relieve symptoms and give you back what you can do in a day — not to make you live longer or to prevent a future heart attack. When this was tested in a randomised trial (DECISION-CTO), opening the artery on top of good medicines did not reduce death, heart attack or stroke. What it does improve — and a sham-controlled trial in 2026 (ORBITA-CTO) confirmed the benefit is real, not just in the mind — is angina and quality of life. So if your symptoms are mild, medicines alone are a perfectly reasonable choice.

Because the artery is completely blocked, and the blockage is not fresh clot — it is old, organised, often hardened tissue with a firm cap at each end. The vessel beyond it is faint and has to be lit up by injecting the other artery at the same time. Getting a wire through that old, hard channel, and being certain it stays in the true channel of the artery, is the delicate part, and it can take time and more than one technique. That is why CTO work is treated as a separate skill rather than a routine angioplasty.

There is more than one way in, and a good CTO operator is ready to switch. If steering a wire straight through from the front does not work, we can travel through the wall of the artery and re-enter beyond the block, or approach it backwards through the natural detours from the other artery — the retrograde route — or use a newer technique that injects a tiny amount of contrast to open the path (hydrodissection). And if none of that is working safely on the day, the right decision is often to stop and return for a planned second attempt rather than push on; success on a second, better-prepared sitting is common. Even in expert hands, about one attempt in eight does not cross — and knowing when to stop is part of doing this well.

It carries a few risks a routine angioplasty does not, and they are worth naming. Because we are working through a complete blockage, there is a somewhat higher chance of making a small hole in the artery (a perforation); rarely that causes bleeding into the sac around the heart, which needs draining. The case is longer, so there is more X-ray and more dye. In large expert registries the overall rate of a serious complication is around three in a hundred, with bleeding around the heart under one in a hundred, and it is higher in the most complex blocks. Set against that, the alternative for the right patient is symptoms that medicines could not control.

They are real, and we manage them actively rather than hope. A CTO case uses more X-ray and more contrast than a standard angioplasty because it takes longer, so we watch both continuously, keep them as low as the case allows, and pay particular attention if your kidneys are already weak. Very rarely, after a very long case, a patch of skin on the back can redden a few days later, like a mild sunburn, and settles on its own. If your kidneys are a concern, we plan the fluid, the dye and sometimes a staged approach around that.

Yes, and that is a legitimate choice, not a lesser one. Anti-anginal tablets — beta-blockers, calcium-channel blockers, long-acting nitrates and others — genuinely control symptoms for many people, and a major trial showed that medicines alone are a reasonable first strategy for a CTO. The procedure is for when good medicines are not enough, or when taking several of them brings its own side effects. We usually work to get the medicines right first, and offer the procedure when they fall short.

It depends on the whole picture — how many arteries are involved, whether you are diabetic, how strong the heart muscle is, and your own wishes. A CTO in one artery, in someone otherwise suitable, is often treated through the wrist. But when there is complex disease across several arteries, bypass surgery — which sidesteps the blockage rather than crossing it — can be the better long-term answer, and that decision belongs to a Heart Team discussion with a cardiac surgeon. Where surgery genuinely serves you better, I will say so and arrange it.

Most people whose symptoms were truly coming from the blocked artery feel a real difference — more able to walk, climb and exert themselves, on fewer tablets. But I will not promise everyone a complete cure: in the sham-controlled trial the improvement was solid but moderate, and some patients still needed some medication afterwards. That is why we take care beforehand to confirm the symptoms are actually coming from this artery. Opening a CTO that was not the cause of your symptoms will not make you feel better, and it is my job to be sure it is before we start.

Age by itself is not the deciding factor. What matters is your kidney function, whether you can take the blood-thinning tablets a stent needs, how strong your heart muscle is, and what else you are living with. For many older people, a planned wrist procedure that avoids opening the chest is the gentler option — and because a CTO is never an emergency, there is time to weigh it up properly and decide whether it is worth doing for the way you want to live.

A CTO case tends to cost more than a routine angioplasty because it uses more equipment — more wires and specialised microcatheters, sometimes dedicated re-entry or retrograde kit, often more than one stent, more dye and more lab time — and a staged second attempt, where one is needed, is a second procedure. Most insurers cover angioplasty for a documented indication, but the individual consumables are where policies differ, so we check your specific cover and start any pre-authorisation before scheduling rather than on the day. For a figure specific to your case and policy, please book a consultation.