ObjectiveTo compare the perioperative and mid-term follow-up outcomes of patients undergoing coronary endarterectomy combined with coronary artery bypass grafting (CE-CABG) versus those undergoing CABG alone. MethodsA retrospective cohort of 2 070 patients who underwent surgery for coronary artery disease at the Department of Cardiac Surgery, Guangdong Provincial People's Hospital between 2016 and 2024 was included. Patients were excluded if they had missing data, concomitant valve, aortic, or congenital heart surgery, or underwent off-pump CABG. Eligible patients were divided into a CE-CABG group and a CABG group, and 1 : 1 propensity score matching was performed using the "MatchIt" package in R software. ResultsA total of 202 patients were included after matching (172 males, 30 females), with a mean age of (60.3±7.5) years. Baseline characteristics were well-balanced between the two groups (standardized mean difference<0.1 for all covariates). There were no statistical differences in operative mortality (4.0% vs. 4.0%) or early postoperative major adverse cardiovascular and cerebrovascular events (MACCE) (4.0% vs. 5.0%, both P >0.05) between the CE-CABG and CABG groups. The CE-CABG group exhibited significantly prolonged operative time [(401.1±105.9) min vs. (353.3±95.6) min], cardiopulmonary bypass (CPB) time [(206.4±65.2) min vs. (174.6±63.1) min], aortic cross-clamp time [125.0 (101.0, 159.5) min vs. 93.0 (70.0, 126.0) min] and postoperative hospital stay [24.0 (18.5, 33.5) d vs. 21.0 (15.0, 28.0) d] (all P<0.05). During a median follow-up of 33 months (follow-up rate: 93.1%), no statistical differences were observed in all-cause mortality (3.0% vs. 5.5%, P=0.498) or MACCE incidence (14.9% vs. 16.8%, P=0.700) between the two groups. However, the rates of cardiac-related readmission (23.8% vs. 37.6%, P=0.033) and coronary angiography re-examination (13.9% vs. 27.7%, P=0.015) were significantly lower in the CE-CABG group. Conclusion CE-CABG facilitates complete revascularization in patients with diffuse coronary artery disease (DCAD) without increasing operative mortality or the incidence of MACCE. CE-CABG is associated with longer CPB time, aortic cross-clamp time, operative time, and postoperative hospital length of stay. Follow-up results indicate that CE-CABG reduces the rates of cardiac-related readmission and coronary angiography re-examination in patients with DCAD. These findings demonstrate that the CE procedure itself does not increase operative risk and serves as a safe and effective strategy for achieving complete revascularization in patients with DCAD.