Anesthetic Considerations in Off-Pump Coronary Artery Bypass Grafting: A Narrative Review

Background: Off-pump coronary artery bypass grafting (OPCAB) avoids cardiopulmonary bypass (CPB) and may reduce selected perioperative complications, but its technical and hemodynamic demands remain important limitations. Methods: We narratively reviewed the literature indexed in PubMed/MEDLINE and Scopus, supplemented by Google Scholar and reference-list screening, covering January 2000 to August 2026. Priority was given to systematic reviews, meta-analyses, randomized trials, prospective studies, guidelines, and relevant landmark reports. Results: OPCAB may be particularly useful in selected patients at increased risk from CPB or aortic manipulation. Cardiac displacement and coronary stabilization can cause rapid changes in preload, ventricular function, myocardial perfusion, and cardiac output, making invasive monitoring, transesophageal echocardiography, and coordinated hemodynamic management central to anesthetic care. Current evidence does not establish the superiority of volatile anesthesia or total intravenous anesthesia. Comparative studies suggest potential reductions in perioperative stroke, transfusion, renal complications, and hospital stay, although potential stroke benefits depend on the aortic-handling strategy and should not be attributed to avoidance of CPB alone. Concerns remain regarding completeness of revascularization, graft durability, repeat revascularization, and long-term survival. Conclusions: OPCAB should be considered an individualized strategy rather than a universal alternative to on-pump CABG. Optimal outcomes depend on patient selection, surgical expertise, vigilant monitoring, and timely correction of hemodynamic compromise. Potential neurological benefits should be interpreted in relation to the aortic-handling strategy, particularly when an anaortic/no-touch technique is used.