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To maximize procedure success, chronic total occlusion percutaneous coronary intervention should be performed within a structured framework with robust procedural planning. The logistics of ring-fencing catheterization laboratory and chronic total occlusion operators’ time, and ensuring availability of specialist equipment should be established. Careful and appropriate patient selection and preparation should be in accordance with current guidelines. Thorough preprocedure angiographic analysis is vital to characterize the anatomy and complexity of the chronic total occlusion, and is key in determining the initial and subsequent strategies.

Chronic total occlusions (CTOs) represent a spectrum in cardiovascular adaptation to ischemic heart disease. Their prevalence has been well described, with the impact on symptoms, prognosis and management becoming increasingly clear [1]. A mismatch seems to exist between their negative impact on quality of life and prognosis, and physician management strategies [2], which, in contrast to less occlusive disease, are more likely to be conservative and less likely to involve percutaneous revascularization. Reasons for this apparent mismatch have previously included technical inability to durably revascularize patients (both surgically and percutaneously) and a lack of recognition of the beneficial effects of revascularization. To chal lenge these hypotheses require teachable, reproducible technical innovations in percutaneous

When chronic total occlusion percutaneous coronary intervention case failure appears likely, it is important to understand the mode of failure and identify modifiable contributors to failure that could potentially be addressed in the primary case to enable future procedural success. Common antegrade failure modes include: an inability to cross the proximal cap; inability to deliver equipment over a wire past the occlusion; re-entry failure from the subintimal space; and loss of distal visualization owing to compressive subintimal hematoma. The most common retrograde failure mode is an inability to negotiate retrograde collaterals. Modification of the proximal cap with balloon angioplasty during the failed case can lead to improved success rates at repeat attempts. We describe four cases of spontaneous recanalization after failed chronic total occlusion percutaneous coronary intervention, where the initial procedure has served as a ’preplasty’ or ‘investment procedure’.