Chronic total occlusions and highly calcified blockages of the coronary arteries are among the most challenging types of blockages to treat. New techniques such as special guide wires and catheters that can cross total occlusions, or coronary atherectomy systems that can ablate calcified plaque, allow our interventional cardiologists to improve success in these complex procedures. Fractional flow reserve (FFR), intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are also used to improve outcomes in these complex cases. Percutaneous ventricular assist devices are available for short-term hemodynamic support during high-risk coronary interventions.