BACKGROUND The aim of this study was to evaluate long-term results after myocardial revascularization in patients with diffuse and distal coronary disease, and to compare this procedure with the classical approach--indirect myocardial revascularization (revascularization without endarterectomy). METHODS This retrospective study was done in the period of three years, and includes patients operated between January 1, 1985 and December 31, 1990 at the University Clinic of Cardiovascular Surgery, Novi Sad. 500 patients were included and two groups were made. The investigated group consisted of 251 patients with endarterectomy and control group of 249 patients without endarterectomy. Other parameters (age, gender, preoperative hemodynamic parameters etc.) were practically the same. RESULTS Postoperative mortality (PM) during immediate 30 postoperative days was 4.64% in the investigated group, and 1.97% in the control group (total PM = 2.66%). The main causes of death were cardiac (3.74%), and the rest of them were respiratory, renal and cerebral. The highest postoperative mortality according to the localization of endarterectomy was left artery descendent (LAD) in the position of the first septal artery (36.36%). The follow-up study included 500 operated patients. The mean follow-up period was 9 years (0-13 years). Cumulative survival curve and postoperative myocardial infarction curve made by Wilcocxon (Gehan) and Kaplan-Meier methods showed no statistically significant difference between groups after 13 years of follow up. Lower incident of new angina was found in the investigated group (p < 0.01). Most of patients show good physical condition, well toleration of the stress test (Bruce protocol) and no significant impairment of ejection fraction. CONCLUSIONS Despite its long history and development, endarterectomy of coronary arteries is one of the most controversial methods in cardiac surgery. Application of this method was very restrictive mostly because its complexity and very controversial results from one institution to another. Endarterectomy of the first septal artery has the highest operative risk, but it is the method of choice in full revascularization of this region. Despite higher operative mortality, the immediate and long term results of this study show that endarterectomy of the coronary arteries is a method with very acceptable operative risk. CONCLUSIONS Endarterectomy is a good and effective method for direct myocardial revascularization in cases with diffuse coronary disease. It is the best procedure for revascularization of the septum. The number of endarterectomies and low ejection fraction are independent predictors for early and long-term mortality. Endarterectomy is also a method of choice in patients with low ejection fraction and poor coronary bed. Frequent and repeated application of angioplasty, higher incidence of diffuse and distal coronary disease and no available donors for heart transplantation will increase the application of this method. In the future we expect further improvement and complete affirmation of endartrectomy of coronary arteries.