Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the United States, with more than 800,000 adults suffering an acute myocardial infarction (AMI) annually [1].

Nearly 20 % of these patients will have at least one coronary chronic total occlusion (CTO), defined as an epicardial vessel without antegrade flow (Thrombolysis in Myocardial Infarction Grade 0) for a probable or definition duration of ≥3 months, and often with the presence of mature collaterals [2]. Yet despite the high prevalence of CTO's, intervention on these vessels accounts for only 5 % of the overall volume of PCI's performed nationwide [3]. A combination of reasons likely accounts for this finding:1. The technically demanding nature of treating these complex lesions; 2. The steep learning curve required to develop proficiency and expertise; 3. The longer procedural times, higher rates of complications and enhanced costs associated with these interventions compared to even high-risk non-CTO PCIs and 4. A perceived lack of benefit [[4], [5], [6]]. As a result, CTO interventions are now increasingly performed at select and specialized centers consisting of high volume operators with technical success rates as high as 85–90 %, and pooled estimate of complications as low as 5 % [7,8]. Notwithstanding the benefits of complete revascularization following an acute ischemic insult, the hazards associated with a “double jeopardy” event related to collateral-dependence of CTO territories by the infarct-related arteries, and technical advances in contemporary CTO PCI, there is limited data regarding the optimal timing of staged CTO revascularization following AMI [9,10].