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Background: The impact of bifurcations at the proximal or distal cap on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We analyzed the clinical, angiographic, and procedural data of 4,584 cases performed in patients between 2012 and 2020 in a global CTO PCI registry. We compared 4 groups according to the bifurcation location: “proximal cap,” “distal cap,” “proximal and distal cap,” and “no bifurcation.” Results: The CTO involved a bifurcation in 67% cases, as follows: proximal cap (n = 1451, 33%), distal cap (n = 622, 14%), or both caps (n = 954, 21%). “Proximal and distal cap” cases had higher J-CTO compared with “proximal cap,” “distal cap,” and “no bifurcation” cases (2.9 ± 1.1 vs 2.5 ± 1.1 vs 2.4 ± 1.2 vs 2.0 ± 1.2, P < 0.0001), and they were also associated with a lower technical success rate (79% vs 85% vs 85% vs 90%, P < 0.0001), higher pericardiocentesis rate (1% vs 1% vs 0.2% vs 0.3%, P = 0.02), and higher emergency coronary artery bypass graft surgery rate (0.3% vs 0% vs 0% vs 0%, P = 0.01). Conclusion: More than two-thirds of CTO PCIs involve a bifurcation, which is associated with lower technical success and higher risk of complications.