Complex Coronary Artery Disease

With recent increase in percutaneous cardiac intervention (PCI) the patients undergoing coronary artery bypass (CABG) are getting more complex with other medical problem. [1] In some patients standard surgical or percutaneous intervention is no longer available due to its complexity. We define complex coronary artery disease (CAD) as condition not amenable to percutaneous coronary intervention and standard surgical intervention. Conditions for complex CAD include necessity of reoperative CABG, coronary endarterectomy, calcified aorta and trans‐ myocardial laser revascularization (TMR). We will discuss each topic with preoperative workup including history and physical, tests and images. Operative steps will be discussed as well as outcomes and evidence that support the treatment. Complex CAD is a challenge for the cardiac surgeons and advanced technique and strategies are required to treat this difficult condition surgically. Reoperative CABG can be performed with proper preoperative assessment and surgical planning. Diffusely calcified CAD can be treated with coronary endarterectomy or TMR. In case of porcelain aorta, circulatory arrest, off-pump bypass or bilateral internal thoracic artery graft may be used. A combination of these modalities is likely necessary for cardiac surgeons in the future to treat patients with complex CAD.