66 year old male patient with past medical history of hypertension, dyslipidemia, diabetes mellitus type II, ex-smoker presents with complaints of left foot pain at rest and non-healing wound on the left first and second toe (Rutherford class III category 5). Peripheral angiogram performed showed non obstructive disease of the right superficial femoral artery with significant stenosis of the distal right anterior tibial and distal posterior tibial artery. Non obstructive disease of the left superficial femoral artery with significant stenosis of the mid left posterior tibial and CTO of the left anterior tibial artery which reconstitutes distally via peroneal artery collaterals. Patient currently planned for an endovascular intervention of the long segment left anterior tibial artery CTO. We will discuss about the endovascular indications and approach towards the below knee vessel CTO.