A chronic total occlusion (CTO) is a condition that occurs when a coronary artery becomes completely blocked for an extended period, typically lasting at least three months. In this condition the artery is completely obstructed, preventing blood flow to the heart muscle beyond the blockage.

CTOs are most commonly caused by a build-up of plaque, which consists of fatty deposits, cholesterol, and other substances, within the coronary artery. Over time, this plaque can harden and narrow the artery, eventually leading to a complete blockage. Other factors that can contribute to the development of a CTO include inflammation, blood clot formation, and the presence of scar tissue from previous heart procedures.

What are the symptoms of a CTO?

When a CTO occurs, the heart may find alternative pathways to deliver blood to the affected area, such as through collateral circulation. However, this is typically insufficient during periods of increased stress on the heart (exercise), and may cause various symptoms including:

  • Chest pain (angina): Patients with a CTO may experience chest pain or discomfort, which can range from mild to severe. The pain may be triggered by physical activity or emotional stress and may subside with rest or medication.
  • Shortness of breath: CTOs can limit blood flow to the heart, leading to reduced oxygen supply. This can result in shortness of breath, especially during physical exertion or activities that require increased oxygen demand.
  • Fatigue: Reduced blood flow due to a CTO can affect the heart’s ability to pump effectively, leading to fatigue or a persistent feeling of tiredness.
  • Reduced exercise tolerance: As a result of a CTO, some patients may find it difficult to engage in physical activities or exercise due to chest pain, shortness of breath, or fatigue.
  • Heart attack: In some cases, a CTO can cause a heart attack if blood flow to the heart muscle is severely compromised and unable to meet the heart’s increased demand during times of stress.

Symptoms may vary from person to person, and some people with a CTO may not experience any symptoms at all. If you’re experiencing any concerning symptoms related to your heart, please contact our team to make an appointment with Associate Professor Ford for an accurate diagnosis and to discuss treatment options.

Treatment options for CTOs include medical therapy, which focuses on managing symptoms and reducing the risk of complications. In cases where symptoms persist or there is a high risk of a heart attack, interventional procedures may be necessary. These may involve using minimally invasive techniques, such as a percutaneous coronary intervention (PCI). A PCI, also known as coronary angioplasty and stenting, works to clear or bypass the blockage and restore blood flow to the heart muscle.

Case Study: Leo’s Story

Leo, a 72-year old man from Western Australia, booked a telehealth consultation with Central Heart for a second opinion after reading about A/Prof Ford’s wider recognition for expertise in angina and minimally invasive treatment of complex coronary blockages.

Leo was experiencing debilitating angina (chest tightness) which limited his ability to walk. Treatment locally had not offered him the recovery that he had aspired towards and he was reluctant to consider their recommendation of open heart surgery (bypass). This led to undertreatment of his angina with ongoing angina despite a recent stent procedure.

Leo travelled across Australia to Central Heart where A/Prof Ford performed a full assessment of his coronary arteries as well as an invasive physiological stress test for all his major coronary vessels in Gosford. Leo had a long segment of blockage within a previously stented right coronary artery which had been blocked for many years and was limiting blood flow to a large part of his heart.

To meet Leo’s goals for improving his quality of life, A/Prof Ford advised that he would benefit from a complex stent procedure (PCI) to reopen his blocked right coronary artery and optimisation of his medications. In Leo’s case this carried significantly higher risks than normal stenting. The alternative treatment was ongoing escalation of medications or consideration of open-heart surgery.

After considering his options with his family, and reassessing how he felt on his current medications, Leo asked A/Prof Ford to perform the high risk intervention. A/Prof Ford teams up with his friend and long-term colleague Professor Andrew Boyle for these complex double operator procedures. Professor Boyle is a cardiologist and researcher who shares a philosophy for providing evidence-based patient care to patients who are deemed too high risk or not suitable to have open heart surgery.

The CTO team: Prof Boyle, Fiona Low (company support), and A/Prof Tom Ford.

Typically, CTO PCIs are performed by two specialists and take up to three hours, accessing the heart from two entry points. In this case, the heart team used a variety of complex techniques, including wires from both sides of the heart, to successfully reconstruct the artery and achieve full restoration of blood flow. The team used stents with imaging guidance which has been proven to reduce the risk of failure by 50 per cent.


The Central Heart team is committed to excellent after care for their patients to support their ongoing wellbeing. Since his surgery, Leo is progressing well. A/Prof Ford has applied to Medicare for approval for a modern injectable treatment (Repatha) to reduce the risk of severe coronary artery disease progression. He has also re-established Leo with a local kidney specialist to help prevent decline in his chronic kidney disease with optimisation of cardiac risk factors.

“My experience with A/Prof Ford has seen a most profound outcome to my life,” said Leo.

“Within a short timeframe A/Prof Ford investigated my situation and scheduled the operation. I flew to NSW on Thursday, he operated on me on Friday, I was discharged on Saturday, and was back in Perth on Sunday.

“I’m grateful to A/Prof Ford for extending my life, helping me return to work, and perform all physical activities without any pain or distress. I’m elated at just being able to walk down the street again.”

Contact Central Heart to find out how we can help

Central Heart is a specialist cardiology practice providing advanced diagnostic tools and minimally invasive treatment options for patients.

The treatment approach for CTOs depends on various factors, including the severity of your symptoms, your overall health, and the extent of the blockage. To determine what’s best for you,  A/Prof Ford will conduct a comprehensive assessment of your heart.

If you have a heart concern, or want a second opinion on your heart health, please contact our friendly team.