Background: Ischemic heart disease was the leading cause of death worldwide. Patients with increasingly complicated anatomic substrates are being referred for surgery as a result of the expanding use of percutaneous coronary procedures to achieve cardiac revascularization. Objectives: This study aimed to compare different techniques of LAD surgical reconstruction using endarterectomy, patched with internal mammary artery or venous graft. Discussing it as a solution for complex LAD anatomy and chronic occlusion in the diffusely diseased atherosclerotic artery. Patients and Methods: This prospective study included 30 patients who underwent CABG surgery at the Cardiac Surgery Department, Sohag Specialized Center and Cardiothoracic Surgery Department, Qena University Hospital. Results: In our study, the pre-operative data were as follows: 21 patients (70%)  had unstable angina, 11 patients (36.7%) had left main artery damage, and 16 patients (53.3%) had previous MI with mean EF of 53.5±9.9.   Half of the patients had NYHA class III, 13 (43.3%) class IV and two patients (6.7%) class II. The endarterectomy group had a significantly higher mean reconstruction length 6.95±1.9 cm than the patch plasty group 4.8±1.2 cm (p=0.008). While the number of anastomoses, cross-clamp time, ventilation time, ICU stay, hospital stay, and inotropic support days showed insignificant differences between the two groups. The endarterectomy group had higher patients with AF, mediastinitis, and bleeding requiring exploration than the patch plasty group. The patch plasty group had higher patients with MI, need for dialysis, stroke and mortality but with statistically insignificant differences. Conclusion: Endarterectomy or patchplasty reconstruction of a diffusely damaged LAD results in good and comparable results in both procedures. The atherosclerotic plaque's features and extent should be taken into account when selecting the procedure. Both groups showed improvement in ejection fraction and NYHA classification postoperative.