 We believe that avoiding cardiopulmonary bypass should be viewed primarily as a step toward avoiding aortic manipulation. Despite the long-term benefits of surgery, some patients may choose percutaneous coronary intervention for the treatment of complex multivessel disease to avoid the morbidity associated with CABG, of which stroke is the most feared. Expert OPCAB surgeons can offer equivalent durability of graft patency as in CABG, with a lower rate of stroke if aortic manipulation is avoided. Authors make mistakes in pointing out that on-pump CABG should be able to be performed under all circumstances, on all patients, at all institutions, regardless of their cardiac volume14. Thus, for example, owing to this rather conflicting evidence, either percutaneous coronary intervention PCI or CABG surgery could be offered to patients with chronic kidney disease, depending on the complexity of coronary disease and comorbidities. If PCI is recommended, appropriate measures should be employed to prevent contrast-induced worsening of renal function. If CABG surgery is the preferred revascularization strategy, the off-pump technique might reduce the risk of acute kidney injury15. 