The cardiovascular system developed early in evolution and is pivotal for the transport of oxygen, nutrients, and waste products within the organism. It is composed of hollow tubular structures and has a high level of complexity in vertebrates. This complexity is, at least in part, due to the endothelial cell lining of vertebrate blood vessels. However, vascular lumen formation by endothelial cells is still controversially discussed. For example, it has been suggested that the lumen mainly forms via coalescence of large intracellular vacuoles generated by pinocytosis. Alternatively, it was proposed that the vascular lumen initiates extracellularly between adjacent apical endothelial cell surfaces. Here we discuss invertebrate and vertebrate cardiovascular lumen formation and highlight the possible modes of blood vessel formation. Finally, we point to the importance of a better understanding of vascular lumen formation for treating human pathologies, including cancer and coronary heart disease.