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Published on: September 15, 2023
Evolution of coronary artery bypass grafting: conventional, minimally invasive, robotic, and hybrid revascularisation
1Department of Surgery, 21 September University for Medical and Applied Sciences, Sana'a, Yemen. h.m.muafa@gmail.com.
Insights
Coronary artery bypass grafting (CABG) offers various surgical approaches for obstructive coronary artery disease (CAD). A personalized Heart Team strategy, considering patient factors and anatomy, guides the selection of conventional, minimally invasive, or hybrid coronary revascularisation techniques for optimal outcomes.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) is a durable treatment for complex obstructive coronary artery disease (CAD).
- Over three decades, CABG has evolved from conventional median sternotomy to include off-pump, minimally invasive direct coronary artery bypass (MIDCAB), robotic-assisted, totally endoscopic (TECAB), and hybrid coronary revascularisation (HCR) techniques.
Purpose of the Study:
- To review the evolution of CABG techniques.
- To compare conventional and minimally invasive CABG approaches.
- To discuss evidence, indications, limitations, and future directions for CABG, proposing a patient selection algorithm.
Main Methods:
- A narrative literature review was conducted.
- Databases searched included PubMed/MEDLINE and Google Scholar.
- Priority was given to contemporary guidelines, landmark trials, systematic reviews, meta-analyses, and large observational series up to June 2026.
Main Results:
- Conventional CABG remains preferred for complex multivessel CAD, ensuring complete revascularisation.
- Minimally invasive techniques like MIDCAB, robotic-assisted CABG, and TECAB may reduce trauma and improve recovery but require specialized training and high-volume programs.
- Hybrid coronary revascularisation (HCR) combines surgical bypass with percutaneous coronary intervention (PCI), though randomized evidence is limited.
Conclusions:
- The future of CABG involves personalized revascularisation strategies selected by a Heart Team, not a single superior technique.
- The optimal approach (conventional, MIDCAB, robotic/TECAB, HCR) depends on individual patient characteristics, coronary anatomy, and institutional resources.
- A practical algorithm aids Heart Team decision-making for patient selection in coronary revascularisation.
Abstract:
Coronary artery bypass grafting (CABG) remains one of the most durable treatments for obstructive coronary artery disease (CAD), particularly in anatomically complex multivessel disease, diabetes, left main disease and ischaemic cardiomyopathy. During the last three decades, the conventional operation performed through median sternotomy with cardiopulmonary bypass has been complemented by off-pump, minimally invasive direct coronary artery bypass (MIDCAB), multivessel minimally invasive coronary surgery, robotic-assisted CABG, totally endoscopic CABG (TECAB) and hybrid coronary revascularisation (HCR). This narrative review summarises the evolution of CABG, compares conventional and minimally invasive approaches, and discusses current evidence, indications, limitations, implementation challenges, future directions and a practical decision algorithm for patient selection. A narrative literature review was conducted using PubMed/MEDLINE, Google Scholar, major cardiology and cardiothoracic guideline documents, and recent open-access reviews and meta-analyses published up to June 2026. Priority was given to contemporary guidelines, landmark trials, systematic reviews, meta-analyses and large observational series. Because this is a narrative review, no formal pooled analysis or risk-of-bias grading was performed. Conventional CABG provides reliable complete revascularisation and remains the preferred strategy for many patients with complex multivessel CAD. The survival value of the left internal mammary artery to left anterior descending artery graft underpins both conventional and minimally invasive strategies. MIDCAB is most established for isolated LAD disease and as the surgical component of HCR. Robotic-assisted CABG and TECAB reduce access trauma and may improve recovery, transfusion requirements and wound morbidity, but they require dedicated training, a specialised team and a high-volume programme to overcome the learning curve. HCR offers a biologically attractive compromise by combining durable LIMA-LAD bypass with PCI to non-LAD vessels, yet randomised evidence remains limited. The proposed algorithm translates these data into a clinically practical Heart Team pathway rather than a purely technique-centred comparison. The future of CABG is not a replacement of conventional surgery by a single minimally invasive method, but a personalised revascularisation strategy selected by a Heart Team. The most clinically relevant question is not whether one technique is universally superior, but which patient, coronary anatomy and institutional environment are best suited to conventional CABG, MIDCAB, robotic/TECAB or HCR.
