Myocardial Revascularization in 2025: A Clinical Perspective on the Evolution of Technologies, Strategic Decision-Making, and Future Horizons.

Coronary artery disease remains the leading cause of death worldwide, causing the field of myocardial revascularization to evolve rapidly. This review synthesizes current evidence and emerging trends, providing clinicians with practical guidelines to support decision-making in practice. Current drug-eluting stents have attained excellent safety profiles, with restenosis rates below 3%. Percutaneous treatment of complex lesions is now routinely feasible, with success rates of 90-95% in experienced institutions. Surgical revascularization remains the standard of care for complex multivessel disease, and total arterial grafting provides a strong long-term survival advantage. Nonetheless, emerging technologies, such as artificial intelligence (AI)-guided interventions, robotic interventions, and precision medicine strategies, have the potential to overcome current limitations and extend advanced therapies to high-risk patients. The optimal revascularization plan increasingly depends on integrating anatomical complexity, physiological significance, patient-specific features, and institution-specific expertise. Heart team-based decision-making is now a necessity, particularly in difficult cases where hybrid strategies might offer particular advantages. Over the coming decade, the extensive use of AI-assisted procedural planning, the broader adoption of minimally invasive treatments, and the establishment of prescription-based personalized medicine protocols are likely to be observed. Success will depend on addressing current challenges, including health disparities, delayed complications, and increasing heterogeneity in the patient population.