Applications of Artificial Intelligence in Chronic Total Occlusion Revascularization: From Present to Future—A Narrative Review

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains among the most complex procedures in interventional cardiology, with variable technical success and heterogeneous long-term outcomes. Conventional angiographic scores such as J-CTO and PROGRESS-CTO provide only modest predictive accuracy and neglect critical patient and operator-related factors. Artificial intelligence (AI) and machine learning (ML) have emerged as transformative tools, capable of integrating multimodal data and offering enhanced diagnostic, procedural, and prognostic insights. Methods: We performed a structured narrative review of the literature between January 2010 and September 2025 using PubMed, Scopus, and Web of Science. Eligible studies were peer-reviewed original research, reviews, or meta-analyses addressing AI/ML applications in CTO PCI across imaging, procedural planning, and prognostic modeling. A total of 330 records were screened, and 33 studies met the inclusion criteria for qualitative synthesis. Results: AI applications in diagnostic imaging achieved high accuracy, with deep learning on coronary CT angiography yielding AUCs up to 0.87 for CTO detection, and IVUS/OCT segmentation demonstrating reproducibility > 95% compared with expert analysis. In procedural prediction, ML algorithms (XGBoost, LightGBM, CatBoost) outperformed traditional scores, achieving AUCs of 0.73–0.82 versus 0.62–0.70 for J-CTO/PROGRESS-CTO. Prognostic models, particularly CatBoost and neural networks, achieved AUCs of 0.83–0.84 for 5-year mortality in large registries (n ≈ 3200), surpassing regression-based methods. Importantly, comorbidities and functional status emerged as stronger predictors than procedural strategy. Future Directions: AI integration holds promise for real-time guidance in the catheterization laboratory, robotics-assisted PCI, federated learning to overcome data privacy barriers, and multimodality fusion incorporating imaging, clinical, and patient-reported outcomes. However, clinical adoption requires prospective multicenter validation, harmonization of endpoints, bias mitigation, and regulatory oversight. Conclusions: AI represents a paradigm shift in CTO PCI, providing superior accuracy over conventional risk models and enabling patient-centered risk prediction. With continued advances in federated learning, multimodality integration, and explainable AI, translation from research to routine practice appears within reach.