Although recent consensus has clearly defined chronic total occlusions (CTO), attempted percutaneous coronary intervention (PCI) remains low. Histopathologically, CTOs are characterized by fibrous caps, varying degrees of plaques, and neovascularization, with both increasing with the age of the CTO. Multiple registries and studies show that successful PCI of CTOs can improve symptoms, left ventricular function, and mortality. There is overwhelming evidence that very low restenosis and reocclusion rates can be obtained with drug eluting stents after recanalization of CTOs. PCI should be considered the preferred initial revascularization modality in patients in whom a high procedural success rate may be anticipated. Novel techniques have greatly enhanced procedural success, and include ''parallel'' and ''seesaw'' wire techniques, balloon anchoring, subintimal tracking and reentry (STAR), retrograde approach, contralateral injection, and intravascular ultrasound (IVUS) guidance. Improvements in wire technology have largely been responsible for improved procedural success in PCI of CTO, while application of new technologies hold promise to significantly better outcomes. Magnetic resonance imaging (MRI) and multislice computed tomography (CT) are already employed in formulating treatment strategies and their role in the treatment of CTOs is likely to increase.