The clinical experience of utilizing the high TEA as a sole anesthetic technique for coronary bypass grafting surgery was introduced in the late 1990s. Karagoz was the first to describe the successful use of sole TEA without general anesthesia in five patients undergoing beating heart CABG via small lateral thoracotomy while fully awake. A single radial artery graft was interposed between both the left or right internal thoracic artery and the respective coronary vessel. Whereas multi-vessel disease requires median sternotomy, the recent advance is to use high TEA in OPCAB (multi-vessel disease) as a sole anesthetic technique. Thoracic epidural anesthesia provides excellent conditions for OPCAB surgery by dilating the coronary arteries and the ITA, and by reducing heart rate and arrhythmias during manipulation of the heart. The potential risks of endotracheal intubation, such as trauma to teeth or vocal cords or peri-intubational hypoxia, are avoided. Some patients experience hemodynamic compromise related to narcotic medication before intubation, which carries the risk of preoperative myocardial ischemia or infarction in patients with severe coronary artery disease. Besides these intraoperative advantages, postoperative pain management is facilitated by continuous epidural application of analgesic agents. Such effective pain management improves postoperative mobilization and recovery. A problem with this technique is that it is only applicable for highly selected patients with good ventricular function where there is lower risk of hypotension during manipulation of the heart, and less risk to convert to on-pump CABG. There are two main concerns: unintentional opening of the pleural cavity, and possible patient movement during surgery. However these concerns can easily be addressed with meticulous care.