While primary percutaneous coronary intervention (PCI) remains the gold-standard reperfusion therapy for ST-elevation myocardial infarction (STEMI), a subset of patients is unsuitable for PCI because of anatomical, technical, or clinical constraints. This chapter examines the evolving role of emergency coronary artery bypass grafting (CABG) in STEMI, tracing its progression from a primary reperfusion approach to a selective treatment reserved for high-risk cases. Contemporary registry data indicate that surgery is now performed mainly in the most critically ill patients—those with cardiogenic shock, failed PCI, mechanical complications, or complex coronary anatomy. The timing of surgery is discussed, with evidence suggesting increased risk with early (<24 h) CABG, but also recognising that unnecessary delay may be harmful in unstable patients. Perioperative considerations, including conduit selection, off-pump surgery and myocardial protection strategies, mechanical circulatory support, and antiplatelet management, are critically reviewed. Although CABG cannot rival PCI’s speed in achieving reperfusion, it remains indispensable in carefully selected cases, underscoring the importance of multidisciplinary decision-making and institutional expertise to optimise outcomes in this challenging patient group.