The never-ending story: on-pump and off-pump coronary artery bypass grafting versus percutaneous coronary intervention and long-term survival

European clinical practice guidelines support that coronary artery bypass graft (CABG) surgery is the treatment of choice for patients with triple-vessel and left main coronary artery disease, in patients with complex coronary artery disease according to the SYNTAX score, in diabetics and in those with poor left ventricular function [1]. The benefits of CABG are well established in specific subsets of patients, although substantial and acrimonious debate has populated medical and non-medical literature and has been an integral part of multiple discussions in all sorts of professional gatherings [2, 3]. Since the pioneering work of Favaloro [4] and others, CABG has evolved into a gold standard of therapy and continues to evolve. Additional surgical debate is still ongoing regarding the performance of the operation with the use of cardiopulmonary bypass or selecting the off-pump approach; however, most studies on the latter have limited follow-up not longer than 5 years [5]. With regard to the use of conduits for revascularization, it is out of doubt and discussion that using the left internal mammary artery or internal thoracic artery depending on the taste of each is the way to go. This is supported by a myriad of studies [6]. On the other hand, the multiple/complete arterial revascularization strategy is also a matter of controversy and analysis. Recent information supports the need for an increasing usage of this strategy, which has to be adapted to the patient [7, 8].