Since its pioneering years, interventional cardiol ogy has faced the hurdle of dealing with the spe cial case of chronic total occlusion (CTO). Long considered to be the ‘last frontier’ of percutane ous coronary interventions, it is only in the last decade that we have finally observed a significant breakthrough in this challenging field, mostly owing to new techniques and materials coming from Japan. Chronic total occlusion procedures now con stitute approximately 10–20% of all angio plasty operations at highvolume hospitals [1]. Advances, mainly in guidewire technology, and the develop ment of new techniques have increased success rates up to an astounding 90% in specialized cent ers with experienced operators [2]. Concomitantly, a reduction of the CTO restenosis rate has been observed with the advent of drugeluting stents [3]. New data have also highlighted the clinical benefits of CTO revascularization, which, in addition to angina relief, include improvement of left ventricular function, a reduction of major adverse cardiac events and perhaps increased sur vival rates [4]. However, an important hurdle on the road to wider utilization of CTO revascu larization is that these are long, expensive pro cedures that expose the operators to high doses of radiation. A particularly steep learning curve also exists. Complexity of procedures and limited familiarity with new techniques may often lead to premature interruption of procedures, causing both physician and patient frustration and rep resenting a common reason for referral to bypass surgery or for choosing medical treatment. Strict adherence to recently developed guidelines [5], especially concerning patient selection, equip ment, facilities and proctoring, is thus, in our opinion, essential for an adequate setup and maintenance of a successful CTO program. Recent advances in CTO techniques that have broadened percutaneous coronary intervention indications and improved success rates can be categorized into anterograde and retrograde approaches [6]. In the presence of visible con tralateral collaterals, operators now widely use bilateral injections to allow for simultaneous anterograde and retrograde filling of the target vessel. Anterograde, parallel wire, controlled dissection and microchannel penetration tech niques have been developed [7]. Techniques for retrograde penetration of the distal CTO cap are various, with the controlled anterograde and retrograde tracking [8], especially in its ‘reverse’ variety, being particularly popular. However, no consensus exists for s election of the initial approach to a CTO.