Chronic total occlusions (CTO) are common, and found in approximately one third of patients with significant coronary artery disease who undergo angiography. CTO constitute one of the main criteria when selecting between angioplasty and bypass surgery. Angioplasty for CTO is intricate and requires excellent operator skill, but even when performed under the best circumstances, it is plagued by lower success rates when compared to non-total occlusions. The main difficulty with CTO lies not with choosing which stent to use, but rather occurs during earlier steps of crossing the lesion and advancing the wire into the true lumen of the distal vessel. Having accomplished this, the rates of restenosis are prohibitively high. Mehran, Dangas and an international team of experienced operators offer the reader sound advice on the evaluation and management of CTO in both the coronary and peripheral vascular systems. Their practical guidance should aid all those working with this difficult subset of patients.