What represents complete surgical myocardial revascularization in 2026?

PURPOSE OF REVIEW: Contemporary coronary artery bypass grafting (CABG) has traditionally defined complete revascularization anatomically; however, accumulating evidence suggests that angiographic stenosis severity alone does not reliably reflect myocardial ischemia or predict durable graft function. This review discusses the emerging transition from anatomy-based to physiology-guided complete revascularization and its relevance to contemporary CABG practice. RECENT FINDINGS: Recent studies demonstrate that the prognostic impact of complete revascularization varies according to conduit strategy, target-vessel physiology, and graft durability. Competitive graft flow remains an important limitation of anatomy-based CABG, particularly in arterial composite grafting. Emerging evidence suggests that physiology-guided strategies using fractional flow reserve, computed tomography-derived fractional flow reserve (CT-FFR), and intraoperative transit-time flow measurement (TTFM) may improve target selection, reduce unnecessary grafting, minimize competitive flow, and optimize graft patency. Integration of preoperative CT-FFR with intraoperative TTFM has emerged as a complementary approach for physiology-guided surgical revascularization. SUMMARY: The concept of complete revascularization is evolving from anatomical completeness toward durable physiologic myocardial revascularization. Integration of CT-FFR and TTFM may improve surgical planning, graft assessment, and conduit durability, potentially enhancing long-term outcomes. Further randomized studies are needed to establish standardized physiology-guided CABG strategies and define their impact on long-term graft patency and survival.