Supplemental Digital Content is available in the text, Background: In patients with complex true coronary bifurcation lesions (CBLs), Crush or Culotte stenting has been the commonest approaches of percutaneous coronary intervention (PCI). However, the optimal one remains in debate. Methods: A systematic review and meta-analysis of cohort studies searched from PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Chinese National Knowledge Infrastructure (CNKI), VIP information database, and WangFang Data Information Site, to compare the long-term safety and efficacy of PCI with Crush versus Culotte in patients with CBLs. The primary end point was target lesion revascularization (TLR) and secondary end points were a composite of major adverse cardiac events (MACE) including cardiac death (CD), myocardial infarction (MI), stent thrombosis (ST), and target vessel revascularization (TVR) by PCI or bypass surgery, and each individual component at long-term follow-up. Furthermore, omitting each study in turn was used to sensitivity analysis for high heterogeneity of studies. Results: A total of 7 studies were included to perform a meta-analysis, 3 randomized trials and 4 observational studies with 2211 patients, 1281 treated with Crush and 930 with Culotte. There was no significant difference in TLR and MACE between Crush and Culotte [RR 0.76, 95% CI (0.48–1.23), I2 = 57%; RR 0.78, 95% CI (0.47–1.29), I2 = 83%, respectively]. ST tended to be lower in patients treated with Crush [RR 0.61, 95% CI (0.37–1.01), I2 = 23%]. CD and MI were comparable between the 2 groups [RR 0.80, 95% CI (0.43–1.49), I2 = 0%; RR 0.74, 95% CI (0.49–1.13), I2 = 32%, respectively]. TVR was also associated with the similar risk [RR 0.76, 95% CI (0.49–1.16), I2 = 60%]. However, high heterogeneity was detected for TLR, MACE, and TVR, and the source of heterogeneity was DKCRUSH-III study by Chen, SL. Conclusions: In the treatment of coronary bifurcation lesions, TLR and MACE were not significant difference between the Crush and Culotte groups, but TLR and MACE were also regarded as high heterogeneity mainly due to better outcomes achieved by DK Crush and there was a trend toward lower ST in the Crush group. Crush, particularly DK Crush, may be superior to conventional Culotte for treatment of CBLs. PROSPERO registration number: CRD42018111868.