Chronic total coronary occlusions (CTOs) are a frequent finding in patients with coronary disease and remain one of the most challenging target lesion subsets for intervention. CTOs have been reported in approximately one-third of patients undergoing diagnostic coronary angiography. By nature of their complexity, CTO percutaneous interventions (PCIs) are associated with lower rates of procedural success, higher complication rates, greater radiation exposure, and longer procedure times compared with interventions in non-CTO stenoses. Despite these obstacles, reported benefits of successful CTO PCI include a reduction in symptoms and improvement in both ventricular function and survival. This article examines the technical challenges, procedural complications, and possible outcomes associated with CTO PCI.