Complex coronary bypass surgery with endarterectomy: surgical planning supported by computed tomography

Comprehensive preoperative evaluation plays a pivotal role in managing patients with diffuse coronary artery disease, particularly when conventional angiography reveals poor-quality targets. Detailed assessment of coronary anatomy, plaque morphology, vessel wall characteristics and distal vessel patency-especially in totally occluded arteries-is essential for planning complex surgical revascularization. coronary computed tomography angiography offers superior visualization of extra-luminal structures and plaque composition, enabling surgeons to better understand disease distribution and anticipate technical challenges. Diffuse atherosclerotic coronary artery disease presenting with angina is increasingly common, and many such patients are suboptimal candidates for standard coronary artery bypass grafting due to diffuse disease, heavy calcification, thin-calibre distal vessels and poor landing zones. These limitations often necessitate advanced reconstructive bypass techniques to achieve complete revascularization. We present the case of an elderly man with diffuse triple vessel disease, where multimodality imaging-including coronary computed tomography angiography-guided the formulation of a complex yet successful revascularization strategy, resulting in an excellent postoperative outcome.