“What if it was your [left anterior descending artery] LAD?” With the advent of drug-eluting stents (DES), the common answer to this question has changed. In the last decade, the number of bypass surgeries in the United States has fallen to about 365,000 per year. Meanwhile, the number of patients receiving stents has soared to nearly a million in 2006. Clinical evidence in support of this shift is lagging behind. In a recent single center study, DES did not reproduce the short-term and intermediate-term benefits of bare metal stents over coronary artery bypass grafting (CABG) in multivessel disease [1Munir M.S. Ahmed A.H. DeLaughter C.M. et al.Comparison of short- and mid-term outcomes of patients with coronary artery disease treated with drugeluting stents and coronary artery bypass grafting.2007Google Scholar], and despite the lack of long-term data, the majority of DES in the United States is implanted off-label, leading to a higher rate of adverse outcomes and lower long-term effectiveness [2Beohar N. Davidson C.J. Kip K.E. et al.Outcomes and complications associated with off-label and untested use of drug-eluting stents.JAMA. 2007; 297: 1992-2000Crossref PubMed Scopus (240) Google Scholar, 3Win H.K. Caldera A.E. Maresh K. et al.EVENT Registry InvestigatorsClinical outcomes and stent thrombosis following off-label use of drug-eluting stents.JAMA. 2007; 297: 2001-2009Crossref PubMed Scopus (317) Google Scholar]. On the other hand, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery achieved similar short-term outcomes as with DES implantation, but provided superior mid-term outcomes such as freedom from reintervention and angina with known excellent long-term outcomes [4Ben-Gal Y. Mohr R. Braunstein R. et al.Revascularization of left anterior descending artery with drug-eluting stents: comparison with minimally invasive direct coronary artery bypass surgery.Ann Thorac Surg. 2006; 82: 2067-2071Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. Aside from the industry, healthcare providers, and interventional cardiologists, patients themselves propelled the move toward percutaneous intervention based on an understandable aversion to major surgery. Similar to other surgical specialties, we face the increasing demand for minimal invasive techniques, shorter hospital stays, and faster recovery times. Robotic surgery has provided the required technical platform to open the field for endoscopic coronary artery bypass grafting, allowing for safe surgical coronary revascularization without the need for sternotomy [5Argenziano M. Katz M. Bonatti J. et al.TECAB Trial InvestigatorsResults of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting.Ann Thorac Surg. 2006; 81 (discussion 1674–5): 1666-1674Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar] and cardiac arrest [6Fleck T. Tschernko T. Hutschala D. et al.Total endoscopic CABG using robotics on beating heart.Heart Surg Forum. 2005; 8: E266-E268Crossref PubMed Scopus (4) Google Scholar]. However, even with the use of stabilizing devices, adapted instrumentation, and suture material, endoscopic performance of coronary anastomoses remains to be a technical challenge. As an alternative to sutured anastomoses and connection devices, Jacobs and colleagues [7Jacobs S. Holzhey D. Stein H. Mohr F.W. Falk V. Catheter-based endoscopic bypass grafting: an experimental feasibility study.Ann Thorac Surg. 2007; 84: 1724-1728Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] propose a catheter-based endoscopic bypass grafting technique [7Jacobs S. Holzhey D. Stein H. Mohr F.W. Falk V. Catheter-based endoscopic bypass grafting: an experimental feasibility study.Ann Thorac Surg. 2007; 84: 1724-1728Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. Combining endovascular and endoscopic techniques, LIMA to LAD anastomoses were successfully performed through the application of tissue adhesive while protecting the anastomotic site using an angioplasty balloon. Although this technique omits endoscopic suturing or use of a connection device, it does require fluoroscopy capability and a surgeon trained in endovascular techniques. Given the advantage of intraoperative quality control and the advent of integrated revascularization strategies for multivessel coronary artery disease [8Katz M.R. Van Praet F. de Canniere D. et al.Integrated coronary revascularization: percutaneous coronary intervention plus robotic totally endoscopic coronary artery bypass.Circulation. 2006; 114: I473-I476PubMed Google Scholar], this combined skill set may become reality sooner rather than later. Coupled advanced surgical and endovascular techniques achieve promising results and given prudent clinical evaluation may enable us to offer well-balanced revascularization solutions for optimal long-term outcome. Catheter-Based Endoscopic Bypass Grafting: An Experimental Feasibility StudyThe Annals of Thoracic SurgeryVol. 84Issue 5PreviewConstruction of an endoscopic catheter-guided, bonded anastomosis to facilitate total endoscopic coronary artery bypass. Full-Text PDF