A Meta-analysis by Takagi et al. showed a 7% increase in all-cause long-term (≥5 years) mortality in patients undergoing non-extracorporeal surgery compared with patients undergoing extracorporeal surgery. The inclusion criteria for this Meta-analysis were randomized controlled trials with ≥5 years of follow-up or corrected observational studies. After screening 478 citations, a total of 5 randomized controlled trials and 17 corrected observational studies were relevant to the search topic and met the inclusion criteria. A total of 10 4306 patients were enrolled in the 22 included studies. A subgroup analysis of the 5 randomized controlled trials (1486 patients) showed a 14% increase in long-term mortality in the non-extracorporeal circulation group, but there was no statistical difference (HR=1.14, 95% CI: 0.84-1.56; P=0.39); however, a subgroup analysis of the 17 corrected observational studies (102,820 patients) also showed a 7% increase in long-term mortality in the non-extracorporeal circulation group. surgery group had a 7% increase in long-term mortality, and in addition, the non-extracorporeal circulation group had a lower number of anastomosed vessels and incomplete revascularization was more common. A randomized controlled study of Danish extracorporeal versus non-extracorporeal circulation by Houlind et al. reported lower rates of vascular bridge patency in patients undergoing non-extracorporeal surgery. This multicenter trial included a total of 900 patients with extracorporeal circulation or non-extracorporeal circulation coronary artery bypass grafting and aged >70 years. A shortcoming of the study was that only 481 patients (56% of long-term postoperative survivors) underwent angiography at 6 months postoperatively. Among patients who underwent angiography, bridge patency rates were significantly higher in the extracorporeal group than in the non-extracorporeal group and stenosis rates (5% vs. 9%) and occlusion rates (9% vs. 12%) were lower. Secondary endpoints of interest include: (1) the patency rate of the left internal thoracic artery bridge was similar in both procedures (95%); (2) the stenosis and occlusion rates of the venous, radial, and right internal thoracic artery bridges were higher in the non-extracorporeal circulation group; (3) the patency rate of the bridge was higher in the anterior ventricular wall region and lower in the gyral branch and right coronary artery regions, with large differences between the two groups and in favor of the extracorporeal circulation The surgical group. Non-extracorporeal coronary artery surgery became more popular in the 1990s. Proponents of this procedure have good intentions: to reduce the complication rate and mortality of coronary artery bypass grafting. These good intentions were supported by early observational studies comparing extracorporeal and non-extracorporeal circulation procedures, which showed lower in-hospital complication rates and mortality in patients undergoing non-extracorporeal revascularization [1-6]. However, subsequent well-designed post-correction observational studies and randomized controlled studies have questioned these early results: although in-hospital serious complication rates and mortality rates were similar in patients undergoing extracorporeal and non-extracorporeal circulation procedures, patients undergoing non-extracorporeal circulation procedures had fewer anastomosed vessels, incomplete revascularization was more common, and had lower rates of vascular bridge patency [7-18]. In addition, patients undergoing non-extracorporeal surgery have a lower rate of “reversible” complications, such as atrial fibrillation, respiratory distress, and bleeding [7,18]. Particularly disappointing for proponents of non-extracorporeal surgery is that this procedure does not reduce the incidence of postoperative neurocognitive dysfunction compared to extracorporeal surgery [18]. The ROOBY trial included a total of 2203 patients undergoing coronary artery bypass grafting from 18 US VA medical centers [15]. 4752 high-risk patients undergoing coronary artery bypass grafting at 79 medical centers in 19 countries were included in the CORONARY trial [16]. High-risk patients were defined as advanced age and presence of co-morbidities (e.g., carotid stenosis, renal insufficiency, diabetes mellitus, and reduced left ventricular ejection fraction). 2,539 patients of advanced age (>75 years) from 12 German medical centers were included in the GOPCABE trial [19]. To determine whether the finding of no benefit of non-extracorporeal surgery shown in several previous studies comparing extracorporeal and non-extracorporeal surgery was due to the inclusion of patients at low risk or inexperienced surgeons performing non-extracorporeal surgery, both the CORONARY and GOPCABE trials included patients at high risk or advanced age and both took full account of surgeon experience when randomizing groups impact. The results of all 3 studies showed similar 30-day postoperative mortality and incidence of stroke and renal failure requiring dialysis in the extracorporeal circulation and non-extracorporeal circulation surgery groups [15-17]. In addition, the CORONARY and GOPCABE studies showed a similar risk of 30-day myocardial infarction for both procedures. The ROOBY study also analyzed the patency of the bridges and showed that both the saphenous vein and the internal thoracic artery bridges were lower in the non-extracorporeal group. A higher percentage of patients in the non-extracorporeal group required a repeat coronary intervention within 30 days after surgery, suggesting that the effectiveness of the revascularization procedure was poor due to low or incomplete bridge patency. In addition, the ROOBY study also found higher cardiovascular mortality within 1 year postoperatively in the non-extracorporeal circulation group. In conclusion, despite the use of more experienced surgeons to perform the procedure, the inclusion of high-risk patients, and advances in non-extracorporeal circulation techniques, these studies have shown that non-extracorporeal circulation revascularization strategies do not reduce early mortality and the incidence of stroke, myocardial infarction, or renal failure requiring dialysis, and again found that non-extracorporeal circulation patients had fewer anastomosed vessels, incomplete hemodialysis was more common, patency of bridges was lower, and mortality was higher within 1 year after surgery, which are worrisome observations. A study by Takagi et al and Houlind et al further confirmed the results of numerous previous studies showing that patients undergoing non-extracorporeal circulation had fewer anastomoses, more frequent incomplete revascularizations, lower bridge patency rates, and higher long-term mortality than those undergoing extracorporeal circulation. Since the effectiveness of coronary artery bypass grafting is directly related to the patency of the vessel bridge and the degree of complete revascularization, it is not surprising that long-term mortality is higher with non-extracorporeal circulation procedures [20-23]. These observations clearly support that extracorporeal circulation should be used as the procedure of choice for revascularization techniques and that non-extracorporeal procedures should only be used in patients in whom the risk of extracorporeal circulation outweighs the risk of low revascularization outcomes (patients who are not candidates for extracorporeal circulation, such as those with extensive aortic atherosclerosis). Despite the many efforts we have made to improve the non-extracorporeal circulation technique, we should now acknowledge that the use of non-extracorporeal techniques does not achieve the same good hemodialysis results as the use of extracorporeal techniques.