Coronary chronic total occlusions (CTO) represent a considerable challenge to percutaneous revascularization. While historic success rates have been as low as 60%, technological advancements in equipment, contemporary techniques, procedural algorithms, and increased operator experience have resulted in successful CTO percutaneous coronary intervention (PCI) in >90% of cases with safety margins that approximate conventional PCI. However, questions regarding long-term clinical outcomes and procedure durability remain largely unanswered. This is due, in part, to a lack of randomized controlled trials in CTO PCI and to the heterogeneity of CTO lesions, technical approaches, and operator skill sets among published observational studies.