Background The safety of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions in remote hospitals without surgical facilities remains unknown. This study aimed to evaluate three-year outcomes after CTO for PCI in ten centers around China where no on-site coronary artery bypass grafting (CABG) support was available. Methods A total of 152 patients from 10 Chinese hospitals without on-site surgical facilities were prospectively studied. Intra-procedural and in-hospital events were assessed. Angiographic follow-up was indexed eight months after the initial procedure. Clinical follow-up was extended to three years. The primary outcome was the rate of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction and target-vessel revascularization (TVR). Results The incidence of CTO was 7.9% in patients who underwent PCI. Successful recanalization was achieved in 132 patients (86.8%). Compared with patients in the PCI success group, patients with PCI procedural failure had longer lesion lengths ((42.32±92.08) mm vs (27.61±92.85) mm, P=0.023), a higher rate of perforation (25.0% vs 0, P=0.014), and a greater need for pericardial puncture. There were significant differences in MACE in-hospital and at one year and three years between the failure (10.0%, 30.0% and 35.0%) and the success (3.0%, 12.1% and 14.4%) groups (P=0.037, 0.034 and 0.040, respectively). These led to a significant decrease in the MACE-free survival rate at one and three years in the failure group, compared with the success group (P=0.031 and 0.023, respectively). Stump was the only predictor of recanalization success (HR 0.158, 95% CI 0.041-0.612, P=0.008), whereas procedural failure (OR 13.023, 95% CI 6.67-13.69, P=0.002), incomplete revascularization (OR 9.71, 95% CI 2.93-5.59, P=0.005), and total stent length (OR 6.02, 95% CI 1.55-11.93, P=0.027) were three independent predictors of MACE.Conclusions PCI for CTO was unsafe in remote hospitals without CABG facilities. Paying attention to coronary perforation is important for successful procedures.