MinervaBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4141 (Published 14 October 2009) Cite this as: BMJ 2009;339:b4141
All rapid responses
The stenting of a long segment (60mm or more) of a coronary artery
has been termed a “full metal jacket” (FMJ) procedure. The follow-up
results of the largest retrospective study(1) of this type of procedure
have been highlighted in the BMJ(2).
The comment on the reported study states: “Almost a quarter of patients
needed a further procedure for restenosis within the next three years. But
rates of myocardial infarction, stent thrombosis, and cardiac mortality
We agree with this, and would like to add a few points on this
Incidence of neo-intimal proliferation associated with intra-stent
restenosis has been reduced since the advent of drug eluting stents (DES),
allowing interventional cardiologists to treat longer lesions.
However, we should consider:
a) The “reconstruction” of a coronary vessel is often done at the
expense of many side branches along the long stented portion of the
artery. Usually only the larger branches are protected during the
b) This may explain the reported incidence of periprocedural
myocardial infarction (MI), as high as 19% in a previous report(3), and
9.5% for single vessel procedures and 19.0% for multivessel procedures in
the recent study of Sharp(1).
c) As mentioned above, during follow-up, patients may need further
procedures for restenosis. Revascularization procedures should not be
considered only for the percutaneous ones. There could be the need of a
different therapeutic strategy (surgical).
However, covering a long segment of the coronary artery with stents (up to
11.8 cm has been reported), means covering the vessel completely, leaving
very little space for further eventual surgical treatment by conventional
FMJ arteries may still be surgically treated by the means of stent
removal, patch angioplasty, and then surgical bypass. However, this would
become an operation that is not straightforward, with a higher surgical
risk. Nevertheless, we should consider that the patency rate of a bypass
in an endoarteriectomized vessel would be not as long as of one
constructed in a vessel with normal endothelium. Therefore, we could say
that stenting a long segment of the coronary artery, especially the middle
and distal parts, may preclude further surgical management of that artery.
We believe that longer follow-up would be of help in defining routine
coronary management with a FMJ stenting procedure. For the moment, it
would be reasonable to reserve this type of management for selected cases.
Treatment of coronary vessel disease should be evaluated on an
individual basis, considering the different treatment options (medical,
interventional, surgical) available for this pathology. Switching from one
type of treatment option to another should remain possible during the long
term management of these patients.
1 Sharp ASP, Latib A, Ielasi A, Larosa C, Godino C, Saolini M, Magni
V, Gerber RT, Montorfano M, Carlino M, Michev I, Chieffo A, Colombo A.
Long-Term Follow-Up on a Large Cohort of "Full-Metal Jacket" Percutaneous
Coronary Intervention Procedures. Circ Cardiovasc Intervent
2 Minerva. BMJ 2009;339:b4141
3 Lee CW, Park KH, Kim YH, Hong MK, Kim JJ, Park SW, Park SJ.
Clinical and angiographic outcomes after placement of multiple overlapping
drug-eluting stents in diffuse coronary lesions. Am J Cardiol. 2006;98:918
Competing interests: No competing interests