Chronic total occlusion (CTO) intervention remains a challenge in terms of percutaneous coronary intervention (PCI). Traditionally average success rates (60–70% British Cardiovascular Interventional Society—BCIS data), procedure duration, degree of radiation exposure, percieved and real procedural complications and need for specialized operator training and maintenance of procedure volume have led to negative perceptions on the value of CTO PCI. Absence of robust data proving hard end point clinical benefit also raise questions over cost efficacy when traditional markers such an incremental cost-effectiveness ratio (ICER) are used. However in the right patients with real-life debilitating symptoms despite medical therapy, CTO PCI can transform a patient’s quality of life—they being able to walk and exercise with friends and family without having to stop because of angina can be life changing. We know there are a significant number of patients who have life-limiting angina despite medication and who can languish with poor quality of life for many years. CTO PCI done properly so as to get good results can change that. Recent advances in techniques including the retrograde approach as well as newer generation stents have yielded better results and renewed interest in CTO treatment. Therefore, it is beholden to the trainee/new consultant or other interventionist becoming interested in CTO PCI to ensure the following: Learn the technique in a structured formal progressive manner, preferably under the mentorship of another more experienced CTO operator. Do cases in conjunction with experienced colleagues. Become totally familiar with antegrade techniques first. Audit their data including success rates. Look to proctorship when they consider techniques/kit they are not familiar with. Attend live interactive courses as part of their summative experiential learning curve. Understand the principles behind the various techniques and are aware of the complications associated with this sometimes technically demanding procedure. Are fully aware of the issues around contrast-induced nephropathy and especially around radiation protection. This chapter will detail ways of ensuring best practice with most likely chance of success for PCI-CTO. It will provide the evidence base where available and include tips and tricks for best clinical practice.