Background: Metabolic syndrome (METs) is an independent risks for the incidence of cardiovascular diseases. We investigated whether or to what extent the METs and its components was associated with coronary collateralization (CC) in chronic total occlusion (CTO).Methods: This study involved 1709 inpatients with CTO. Data on demographic and clinical characteristics were collected by cardiovascular doctors. The CC condition was defined by Rentrop score system. Subgroup analysis, mixed models regression analysis, score systems and receiver-operating characteristic curves (ROC) analysis were done. Results: Overall, 1709 inpatients were assigned to the Poor CC group (n = 370), good CC group (n = 1339) with or without METs. Compared to good CC, the incidence of METs was higher in poor CC for overall patients. Poor collateralization was present in 9.1%, 14.4%, 19.9%, 18.1%, 35.1% and 54.2% of the six groups, who met the diagnostic criteria of MetS 0, 1, 2, 3, 4 and 5 times. For multivariable logistic regression, quartiles of BMI remained the risk factors of CC growth in all subgroups (adjusted OR = 1.728, 95% CI 1.518-1.967, P < 0.001 all patient group , adjusted OR = 1.827, 95% CI 1.484-2.249, P < 0.001 No-METs group and adjusted OR = 1.771, 95% CI 1.484-2.115,P < 0.001 METs group). After adjustment for potential confounding factors, METs was an independent risk factors of CC growth in several models. Assigning a score of one for each components, this score system had significant predictive value for the CC conditions by Receiver-operating characteristic(AUC: 0.622, 95%CI: 0.588-0.655) .Conclusions: METs, especially for body mass index, confers greater risk for CC formation in CTO. Score systems may help to predict CC condition.