Acute coronary syndrome (ACS) comprises a spectrum of disease that includes unstable angina, non-ST-elevation myocardial infarction, and ST-elevation myocardial infarction. Clinical management of patients with ACS has greatly evolved over the last two decades, but ACS remains an important cause of morbidity and mortality in patients with coronary artery disease. This narrative review describes the indication, timing, and approaches to surgical revascularization in the context of ACS. In particular, the review discusses and compares the utilization of off-pump coronary artery bypass grafting (CABG) vs. conventional on-pump CABG. Other surgical interventions, such as totally endoscopic coronary artery bypass and hybrid coronary revascularization, are also reviewed.