What are the surgical revascularisation options for coronary artery disease (including conventional on‑pump coronary artery bypass grafting, off‑pump coronary artery bypass grafting, minimally invasive direct coronary artery bypass, robotic‑assisted or totally endoscopic coronary artery bypass, and hybrid coronary revascularisation) and how should they be selected?

CABG Surgical Options and Selection Strategy

For patients requiring coronary artery bypass grafting, conventional on-pump CABG with left internal mammary artery (LIMA) to the left anterior descending artery and radial artery grafts to other significant lesions is the gold standard approach that provides superior long-term survival, reduced adverse cardiac events, and improved graft patency compared to alternative techniques. 1

Primary Surgical Approach: Conventional On-Pump CABG

Conventional on-pump CABG remains the preferred technique for most patients requiring surgical revascularization, particularly those with:

• Left main disease (Class I, Level A recommendation for survival benefit) 1
• Triple-vessel disease with diabetes (Class I, Level A recommendation) 1, 2
• Triple-vessel disease with LVEF ≤35% (Class I, Level B recommendation) 1, 2
• Complex multivessel disease with SYNTAX score >22 1, 3

Optimal Conduit Selection Algorithm

The radial artery is recommended as the preferred conduit for the second most important target vessel after the LAD (Class I, Level B-R recommendation), providing superior patency, reduced adverse cardiac events, and improved survival compared to saphenous vein grafts. 1

Conduit hierarchy for on-pump CABG:

1. LIMA to LAD (mandatory first choice) 1
2. Radial artery to second most important vessel (preferred over saphenous vein) 1
3. Saphenous vein grafts (for remaining targets or when radial artery unavailable) 1

Alternative CABG Techniques: When to Consider

Off-Pump CABG (OPCAB)

Off-pump techniques may be considered in select patients, though the evidence does not demonstrate superiority over conventional on-pump CABG for mortality or major adverse cardiac events. 4, 5

Consider off-pump CABG for:

• Patients with severe aortic atherosclerosis (to avoid aortic manipulation)
• Patients with high risk of stroke from cardiopulmonary bypass
• Severe chronic kidney disease where minimizing bypass time is desired

Critical caveat: Off-pump CABG requires significant surgical expertise and may result in less complete revascularization in complex anatomy. 4, 5

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)

MIDCAB is a reasonable option for isolated LAD disease only when:

• Single-vessel LAD disease requires revascularization
• Patient anatomy is suitable for LIMA-to-LAD grafting via small thoracotomy
• No other vessels require grafting 4

Do not use MIDCAB for multivessel disease requiring complete revascularization, as outcomes favor conventional CABG. 4, 3

Robotic-Assisted and Totally Endoscopic CABG

These techniques remain investigational with limited outcome data. They should only be performed in highly specialized centers with extensive experience, and are not recommended as standard practice given the lack of evidence demonstrating equivalent or superior outcomes to conventional CABG. 4

Hybrid Coronary Revascularization

Hybrid revascularization (combining MIDCAB LIMA-to-LAD with PCI to other vessels) may be considered in highly selected patients with:

• Isolated LAD disease plus non-complex single-vessel disease in other territories
• High surgical risk precluding conventional CABG
• Anatomy favorable for both surgical and percutaneous approaches 4

Critical limitation: Hybrid approaches lack robust long-term outcome data and should not be considered equivalent to conventional CABG for multivessel disease. 3, 5

Patient Selection Algorithm for CABG vs PCI

Mandatory CABG Indications (Over PCI)

CABG is the definitive choice for:

• Diabetes with multivessel disease (any SYNTAX score) - provides survival benefit and reduced MACCE 1, 2, 3
• Left main disease with SYNTAX score >22 1
• Triple-vessel disease with SYNTAX score >22 1, 2, 3
• LVEF ≤35% with multivessel disease (surgical candidates only) 1, 2

CABG Preferred (Strong Consideration)

CABG should be strongly favored for:

• Triple-vessel disease with normal LVEF (may improve survival, Class IIb recommendation) 1
• Left main disease with SYNTAX score 23-32 (lower MI and repeat revascularization rates) 1

PCI Acceptable Alternative to CABG

PCI is a reasonable alternative when:

• Left main disease with SYNTAX score ≤22 and equivalent completeness of revascularization achievable 1
• Multivessel disease with SYNTAX score ≤22 in non-diabetic patients 1, 3
• High surgical risk (elevated STS score) 1

Risk Stratification Tools (Mandatory Calculation)

Calculate STS score for all patients being considered for CABG to estimate in-hospital morbidity and 30-day mortality (Class I, Level B recommendation). 1

Calculate SYNTAX score for all patients with multivessel disease to assess anatomical complexity and guide revascularization strategy (Class I, Level B recommendation). 1, 2

Heart Team Approach (Mandatory for Complex Cases)

A multidisciplinary Heart Team discussion is recommended (Class I, Level C) when:

• Optimal treatment strategy is unclear
• Left main or complex multivessel disease
• Diabetes with multivessel disease
• LVEF ≤35% requiring revascularization decision
• SYNTAX score 23-32 (intermediate complexity) 1

The Heart Team must include interventional cardiology, cardiac surgery, and non-interventional cardiology representatives, with patient-centered shared decision-making incorporating patient preferences and goals. 1

Common Pitfalls to Avoid

Do not select PCI over CABG in diabetic patients with multivessel disease - CABG provides superior survival and reduced MACCE (5-year MACCE: 18.7% CABG vs 26.6% PCI, P=0.005). 1, 2, 3

Do not use saphenous vein grafts when radial artery is available for the second most important target vessel - radial artery provides superior long-term patency and survival. 1

Do not pursue off-pump or minimally invasive techniques in complex multivessel disease requiring complete revascularization - incomplete revascularization worsens outcomes. 4, 3, 5

Do not bypass Heart Team evaluation in patients with SYNTAX score >22 - these complex cases require multidisciplinary assessment to optimize outcomes. 1, 2