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.