**1. Introduction**

The rapid evolution of medical therapy, percutaneous coronary interventional techniques and cardiac surgery along with the changing patient profile over the last few decades has required the clinician to make increasingly complex decisions. This has led to significant variations in practices that may be discordant with evidence based clinical practice guidelines. Such variations have an unclear clinical impact. There is hope that with growing efforts to apply multidisciplinary care to the management of complex coronary artery disease (CAD),that we will arrive at more consistent and balanced decisions.

In this chapter, we will explore (1) The history of angiography and angioplasty, (2) the current clinical dilemma (3) the evidence supporting the use of cardiac surgery to improve survival above medical therapy alone, (4) the role of percutaneous approach versus surgery in different populations, (5) the impact of changing technologies/techniques in revascularization, (6) the current discordance between guidelines and clinical practice, and (7) the potential role of a multidisciplinary Heart Team to create a more unified, balanced approach to the treatment of complex CAD.
