A chronically occluded artery (CTO) have not result in clinical symptoms in which case medical therapy alone would be the first-line management option.

Often, however, a CTO can result in intrusive symptoms of angina that are not manageable with medical therapy alone, resulting in a reduction in activity and stamina. In this setting, usually following a number of other investigations including heart imaging to determine viability and ischaemia (the presence of living heart muscle with impaired blood flow), Prof Ruparelia may suggest treatment of the CTO to improve symptoms.

You can eat and drink up until the procedure. If you have an element of kidney failure, you may be asked to attend a little earlier than your planned procedure time so that you can be hydrated prior to the procedure. Please wear comfortable clothing.

It is important you following the specific instructions provided to you by Prof Ruparelia with regards to your medications (especially blood thinning and diabetes medications) prior to your procedure.

CTO PCI does require more complex techniques when compared to more standard coronary stent implantation. As a consequence the risks are a little higher (1-2%) and include pain, bleeding, bruising of the puncture site. There is a very small risk of a stroke, heart attack, damage to heart artery or mortality. Prof Ruparelia shall explain each of these in depth before the procedure.

On the day of your procedure you will be asked to attend. A small cannula is inserted in the arm through which any medication can be administered if required. Your medications will be checked to ensure that you are on the correct regimen - you may require additional anti-platelet therapy.

You are awake through the procedure and some sedation can be administered if you are nervous or anxious.

For CTO PCI, commonly two access routes are required to facilitate treatment. Local anaesthetic is administered to numb the skin in the wrist and likely also leg.

Small tubes are then advanced through the arteries through which contrast is administered to take pictures of the coronary artery with X-ray.

A very thin wire is then advanced to attempt to traverse the chronically occluded coronary artery (CTO). Often wires are advanced through both tubes to facilitate opening of the blockage. Intravascular imaging is almost always used to ensure correct passage of the wire and to aid in the optimal sizing of balloons to stretch the artery open and of stents to ensure long-term patency of the vessel.

The procedure can take up to 2-3 hours and Prof Ruparelia shall ensure that you are as comfortable as possible throughout this time.

If the procedure has been performed via the wrist alone (radial artery) you are able to sit up immediately. A tight band is usually applied around the puncture site and is slowly loosened over two hours. Often in the management of a CTO, the artery at the top of the leg is used. Prof Ruparelia normally closes this with a small plug or suture and you will be asked to lie flat in bed for a couple of hours to aid in healing. Once the team are happy with the puncture site you will be allowed to sit up and then mobilise.

You should aim to be able to go home approximately 4 hours after your procedure. It is important that you have someone to take you home and be with your for the first night at home. You should take care of the punctures sites for a few days to facilitate healing.

Following a coronary stent implantation in accordance with DVLA guidelines you are not permitted to drive for 1 week.