Limited evidence exists regarding the long-term outcomes of true versus nontrue coronary bifurcation lesions (CBLs) treated with current-generation drug-eluting stents and intravascular imaging guidance. The Sapporo Cardiovascular Clinic (SCVC) registry was a prospective, single-center, all-comers registry enrolling 1,727 consecutive patients treated with bioresorbable polymer sirolimus-eluting stent under complete imaging guidance. From this registry, 440 patients with CBLs (25.5%) were analyzed. Patients were categorized into the true and nontrue CBL groups according to the Medina classification (n = 234 and 206, respectively). The primary end point was the cumulative incidence of target vessel failure (TVF) (a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization). The 1-stent strategy was predominantly chosen for the true and nontrue CBL groups (93.9% and 96.2%, respectively). During the median follow-up of 5.4 years, the cumulative incidence of TVF did not differ between true and nontrue CBL groups after adjustment for baseline differences (5-year incidence 22.0% vs 17.7%, adjusted hazard ratio 1.27, 95% confidence interval 0.79 to 2.05, p = 0.32). Although the Medina 0.0.1 lesions were very rare (1.1%), they had the highest rate of TVF among the Medina subtypes. Final kissing balloon inflation technique was associated with a lower incidence of TVF (p = 0.036). In conclusion, imaging-guided percutaneous coronary intervention with bioresorbable polymer sirolimus-eluting stent resulted in comparable long-term clinical outcomes between true and nontrue CBLs, primarily using the 1-stent technique.