Aim The impact of Grade III coronary perforations (G3‐CP) in the setting of CTO‐PCI is not well assessed. Methods and Results We reviewed 7773 CTO‐PCI and 98,819 non CTO‐PCI performed in 10 European centers: G3 perforation occurred in 87 patients (1.1%) during CTO PCI and 224 patients (0.22%) during non CTO‐PCI (p < 0.001). G3‐CP involved the CTO segment in 68% of patients and the retrograde channels in 14% of cases. In the CTO PCI group, wire induced G3‐CP (50.5% vs. 32.5%, p = 0.02) occurred predominantly when dedicated CTO tapered and highly penetrative wires were used. Intra‐procedural and in‐hospital death rates were 4.6% vs. 5.8% and 3.6% vs. 7.5% respectively for CTO PCI and non‐CTO PCI groups (p = NS). At a median follow up of 24 months, the overall mortality and MAE were respectively 7.8% and MAE 19% without difference among groups. Conclusions We showed similar in‐hospital and long‐term outcomes when G3 perforations occurred during CTO PCI and non CTO‐PCI.