BACKGROUND: Coronary chronic total occlusions (CTOs) are related to increased risk of adverse clinical outcomes. The optimal treatment strategy for CTO has not been well established. We sought to examine the impact of CTO percutaneous coronary intervention (PCI) on long-term clinical outcome in the real world. METHODS: A total of 592 patients with CTO were enrolled. 29 patients were excluded due to coronary artery bypass grafting (CABG). After exclusion, 563 patients were divided into the no-revascularized group (CTO-NR group, n = 263) and successful revascularized group (CTO-R group, n = 300). The primary endpoint was cardiac death; secondary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, cardiac death, recurrent myocardial infarction, target lesion revascularization, re-hospitalization, heart failure, and stroke. RESULTS: Percent of Diabetes mellitus (53.2% vs 39.7), Chronic kidney disease (8.7% vs 3.7%), CABG history (7.6% vs 1%), three vessel disease (96.2% vs 90%) and left main coronary artery disease (25.1% vs 13.7%) was significantly higher in the CTO-NR group than in success PCI group (all P < 0.05). Moreover, the CTO-NR group has the lower ejection fraction (EF) (0.58 ± 0.11 vs 0.61 ± 0.1, p = 0.001) and fraction shortening (FS) (0.31 ± 0.07 vs 0.33 ± 0.07, p = 0.002). At a median follow-up of 12 months, CTO revascularization was superior to CTO no-revascularization in terms of cardiac death (adjusted hazard ratio [HR]: 0.27, 95% conference interval [CI] 0.11-0.64). The superiority of CTO revascularization was consistent for MACCE (HR: 0.55, 95% CI 0.35-0.79). At multivariable Cox hazards regression analysis, CTO revascularization remains one of the independent predictors of lower risk of cardiac death and MACCE. CONCLUSIONS: Successful revascularization by PCI may bring more clinical benefits. The presence of low left ventricular ejection fraction (LVEF) and LM-disease was associated with an incidence of cardiac death; CTO revascularization was a protected predictor of cardiac death. Successful revascularization by PCI offered CTO patients more clinical benefits, manifested by lower incidence of cardiac death during follow-up. The presence of LVEF < 0.5 and left main coronary artery disease (LM disease) was associated with an incidence of cardiac death; CTO revascularised was a protected predictor of cardiac death.