Chronic total occlusion percutaneous coronary intervention: 2026 update

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is continually evolving through improvements in strategy, imaging, and equipment. This review provides a summary of the published literature in CTO PCI between September 2023 and April 2025, categorized by procedural outcomes, techniques, complications, and ongoing studies. Recent multicenter analyses report technical success rates exceeding 90% in expert centers, accompanied by significant reductions in angina and dyspnea at long-term follow-up. Despite higher complexity, radiation exposure has significantly decreased during the past decade as a result of equipment upgrades and operator awareness. Procedural refinements such as the use of coronary computed tomography for guidance, intravascular ultrasound guided re-entry, hydrodynamic contrast recanalization, novel retrograde techniques, and artificial intelligence-based tools are improving success and safety. Ongoing randomized trials and large-scale registries will continue to shape practice patterns and refine strategy selection in CTO PCI.