Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains a major challenge in interventional cardiology. Successful recanalization of a CTO can alleviate angina, reduce the need for coronary artery bypass surgery and increase long-term survival. Improving results from the historically quoted success rates of 50% to the levels now routinely quoted by some operators (80-90%), requires not just skill and experience, but also a thorough understanding of the wide array of materials and techniques now available in this area. The decision to attempt PCI of a CTO (versus continued medical therapy or surgical revascularization) requires an individualized risk/benefit analysis, encompassing clinical, imaging and technical considerations.