In patients presenting with an acute coronary syndrome (ACS), treatment of the infarct related artery (IRA) is key for improving outcomes and is most often achieved with percutaneous coronary intervention (PCI). In addition to the IRA ACS patients often have multivessel coronary artery disease (MVD), including chronic total occlusions (CTOs): 10–26 % of non-ST elevation myocardial infarction (NSTEMI) patients have a CTO in a non-IRA [ 123 ]. Several studies have shown worse outcomes in both NSTEMI and ST elevation myocardial infarction (STEMI) patients and concomitant CTOs [ 345 ].