Patients with end-stage renal disease (ESRD) are at increased risk of death from cardiac causes. Traditionally, coronary artery disease (CAD) in this patient population has been treated conservatively. Despite the scope and complexity of the problem highlighted from large databases, there is a paucity of controlled, randomized data in patients with ESRD. In this paper we address the following two questions: 1) Should the patient with ESRD and CAD be treated with medical therapy or with mechanical revascularization? and 2) Which mechanical revascularization procedure is optimal— surgical or percutaneous? Although the mortality data in favor of coronary revascularization in patients with ESRD and clinically significant CAD is convincing, the data are based solely on retrospective analyses with relatively small numbers of patients. For now, the choice of the revascularization procedure itself must be individualized, taking into consideration such factors as comorbid conditions, coronary anatomy, and the likelihood of achieving complete revascularization. Data from large, prospective, randomized controlled trials are desperately needed to appropriately address the optimal application of coronary revascularization in patients with ESRD.