Background: Successful chronic total occlusion (CTO) Percutaneous Coronary Intervention (PCI) demonstrates significant clinical benefits, but comparative outcomes between antegrade and retrograde approaches are still lacking in Egypt. Results: We enrolled 152 patients in the period from December 2018 to May 2021. They were referred for CTO-PCI procedures at the National Heart Institute's catheterization laboratory. The studied population was categorized into two groups: The first group: patients with an antegrade approach. The second group: patients with a retrograde approach. The highest percentage of CTO vessels affected was RCA (43.4%). The mean duration of CTO was 12 months with a J CTO score of 3. Approximately more than three-fifth (90.1%) of the studied population had technical success. The technical success was higher in the retrograde group (96.1%) compared to 84.0% of that in the antegrade group (P= 0.012). Technical success was (92.6% & 98.0%) in epicardial and septal collaterals, respectively, with no statistically significant difference. Mean of total procedure time (min.) was 140 ±55 while mean of total contrast volume (ml) used was 301 ±107 while median of Total radiation dose (mGy) was 11925. Conclusions: In our institution, the retrograde approach is safer and more effective than antegrade CTO-PCI but involves longer procedure duration, greater radiation exposure, and more contrast material usage. Septal collateral channels were more secure than epicardial collateral channels for the retrograde approach.