This is a difficult problem that often plagues patients with coronary artery disease and one that I often face in my clinical work. In fact, there are criteria (Syntax score) in the professional field on how to choose, but the guidelines are only a recommendation and each patient has different circumstances, so it is impossible to generalize. First, a brief description of the differences between the two procedures. To use an analogy, coronary artery disease is a blockage of the water pipe supplying the heart with scale (usually the stenosis is above 70%), resulting in ischemia of the heart, which needs to be repaired by a plumber (re-vascularization treatment), and the repairer has two options: First, to put a stent in the original water pipe to support the stenosis and restore the diameter of the narrowed water pipe (stent implantation). The second is to find another plumbing material (internal mammary artery, saphenous vein, etc.) and build another line from the large plumbing to the distal end of the stenosis to restore the distal blood supply (coronary artery bypass grafting, commonly known as bypass surgery). The two surgical procedures have the same purpose, but stenting is a minimally invasive procedure, which is routinely performed through the radial artery (at the wrist of the forearm), with little trauma and no need for general anesthesia, and can be performed immediately after surgery, with an average hospital stay of 5 days; whereas bypass surgery routinely requires open-heart surgery (there are also minimally invasive surgical procedures, but only one bridge can be built, which is not yet widely carried out), which requires general anesthesia and routinely requires extracorporeal circulation, with greater trauma and slower recovery. The recovery is slower. The cost of both procedures varies depending on the specific vascular condition. Stent or bypass? First, consider the condition of the patient’s vessels, which is the core of the guidelines (Syntax score). For example, if there is a relatively simple lesion in one vessel, then undoubtedly, stenting is definitely the first choice, with less trauma, faster recovery, lower cost, and better prognosis; of course, for individual anterior descending lesions, there is also the option of unthoracic robotic LIMA bridge, but it is not mainstream at present; on the contrary, if the patient’s coronary lesion is severely diffuse calcification, distortion, and complex combined stenting procedure (left main stem, bifurcation, chronic occlusion, etc.), (Syntax score of 33 points or more), the guidelines tend to bypass treatment, but need to depend on the specific situation, the current stent surgery technology is advancing rapidly, the success rate and safety of complex procedures (left main stem, bifurcation, chronic occlusion) are very high, you can also choose stent treatment, specific to the experienced heart center consultation. Second, consider the general condition of the patient. Surgical bypass surgery should fully assess the patient’s surgical risk before surgery, such as EuroScore score, high-risk factors include advanced age, renal insufficiency, chronic obstructive pulmonary disease, diabetes, history of cardiac surgery, heart failure, history of old infarction, complexity of surgery, etc., high-risk patients surgery is contraindicated, so many patients themselves do not have the conditions for surgery; and stent Stent implantation is less invasive and can be performed safely for the above-mentioned high-risk patients. In addition, for some elderly patients (over 80 years old), patients with advanced tumors, and patients in urgent need of non-cardiac surgery, they need to improve their quality of life and ensure surgical anesthesia, so non-complete hemodynamic reconstruction is desirable, which means that there is diffuse, multiple coronary stenosis, and short stents can be placed at the most severe stenosis (criminal lesion) to effectively relieve symptoms, improve patients’ quality of life, and withstand non-cardiac surgery. surgery. Third, consider the patient’s prognosis. The most important aspect of recanalization treatment is the patient’s prognosis, which is the starting point for the Syntax score in the guidelines. Compared with bypass surgery, the proportion of re-operation is significantly higher in stent implantation, which is often related to restenosis after stenting, and the proportion of restenosis within the stent in the era of drug stenting is about 10% or less, requiring another interventional procedure, in which bypass surgery is advantageous; however, the current domestic routine bypass surgery uses an arterial bridge and two venous bridges. According to statistics, the 10-year patency rate of venous bridges is only 50%, which means that about half of the patients need to be revascularized again 10 years after bypass surgery, and the second bypass surgery is only carried out by a few heart centers and very few experienced surgeons in China, and the risk of surgery is significantly higher than the first bypass, which often puts patients in a dilemma (now you can choose stenting surgery). Therefore, for younger patients with coronary artery disease (<60 years old), I recommend stent implantation as much as possible, so that even if a stent cannot be placed later, bypass surgery can be performed later. Fourth, consider the patient's psychological acceptability. This is a factor that is often overlooked by guidelines or physicians, but is very important. I have encountered such a patient in the clinic, an elderly woman, frequent angina attacks, diffuse and serious coronary lesions, stent surgery can not be completely reconstructed, surgical bypass therapy is recommended, but the patient adamantly refused to open-heart surgery, very resistant, the doctor and family repeatedly work in vain, but finally gave the implementation of partial hemodynamic reconstruction (only a stent was placed in the heaviest place), combined with strong drug In the end, partial hemodialysis was performed (only a stent was placed in the heaviest part), and in combination with strong medication, angina was effectively controlled, and the condition was stable for many years. There was also this patient, a middle-aged male, with recurrent resting angina and severe lesions in the proximal segment of the anterior descending branch suggested by imaging, and stenting was recommended. The above two examples illustrate the difference between medical guidelines and clinical practice. In clinical practice, we should take into account the psychological factors of patients, fully communicate with them psychologically, and achieve "two-hearted treatment" in order to better solve patients' illnesses. Stenting or bypass? This answer is sometimes not clear, need to individualize the patient's specific condition, comprehensive situation and psychological factors, when it is difficult to choose, the cardiology and cardiac surgery surgeons need to fully communicate with the patient and family to decide together. Of course, medical science is constantly advancing, and the clinical application of absorbable stents, advances in minimally invasive surgery, etc. will bring new and more positive options for patients!