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The Coronary “Full Metal Jacket”: Unique PCI Strategy and Long-term Outcomes
John Lawrence, MD1; Michael P. Savage, MD1; Sheldon Goldberg, MD2; David L. Fischman, MD1
From the 1Thomas Jefferson University Hospital, 2Pennsylvania Hospital, Philadelphia, PA
The term “full metal jacket,” typically defined in the literature as one continuous segment of intracoronary stenting measuring >60 mm, was first used to describe extensive coronary stenting by Kornowski et al in 1998.2,3 FMJ stenting has commonly been utilized to treat long, diffuse, complex coronary lesions. Although surgical revascularization remains an important strategy in treating diffuse coronary disease, often there are no acceptable distal targets for graft insertion. This, coupled with the continued technological optimization of drug-eluting stents, helps to illustrate how FMJ stenting remains a commonly utilized procedure in clinical practice after its first description in the Journal of Invasive Cardiology. Despite some understandable trepidation regarding the use of FMJ stenting, there is an abundance of data illustrating the efficacy and acceptable long-term clinical outcomes of this technique in treating patients with diffuse coronary disease.
The patient described in this report was treated with a total of 90 mm of Palmaz-Schatz bare-metal stents as part of an investigational study conducted prior to the STRESS randomized trial and 5 years before the United States Food and Drug Administration approval of the Palmaz-Schatz stent.4 To our knowledge, the original publication in 1989 was the first report of coronary stenting for such diffuse disease, a technique coined the FMJ many years later. Accordingly, the clinical follow-up status 30 years after the seminal report is unique. Although the patient has required multiple PCIs in the intervening three decades, remarkably the patient has survived without suffering a myocardial infarction or undergoing coronary artery bypass graft surgery. We recently published the 30 year follow up on this patient in the July issue of the Journal of Invasive Cardiology.
With the advent of drug-eluting stents, numerous studies have expanded on the outcomes of the FMJ in both de novo coronary lesions and chronic total occlusions. Despite the complexity of diffuse coronary artery disease, these observational studies have demonstrated favorable results with both first- and second-generation drug-eluting stents, with acceptable rates of stent thrombosis and target-vessel revascularization at long-term follow-up (up to 10 years in one study).3,6-9
In addition to serving as a review of the FMJ concept, this case provides a historical perspective of the antithrombotic/antiplatelet therapy of intracoronary stenting. Following the original stenting procedure, the patient was treated with the registry protocol of warfarin for 1 month, dipyridamole for 3 months, and aspirin 325 mg daily, indefinitely. Following his repeat procedures more than a decade later, warfarin was no longer in use following coronary stenting; rather, he was treated with full-dose aspirin (325 mg) and varying durations of clopidogrel (3-12 months), including a 12-month course after his 2004 procedure. The aspirin was decreased to 81 mg in 2008 and clopidogrel was restarted reflective of continuous modification of antiplatelet therapies with stents over the many years. In early 2017, the aspirin was discontinued due to bruising, but the low-dose aspirin was restarted following his procedure later that year. At the time of his last follow-up in 2019, he was taking both aspirin and clopidogrel.
Conclusion
Although FMJ stenting remains a controversial topic in interventional cardiology, there is an abundance of data that support this PCI strategy as a safe and effective option to treat coronary disease in a complex and challenging group of patients. Furthermore, with continued procedural including new generation stents and pharmacological advancements, FMJ stenting may continue to see an increasing utilization. Despite this encouraging prospect, there remains a demand for additional study in this area. In particular, further investigation is needed to determine exactly which patients are likely to benefit most from this unique PCI strategy and to evaluate long-term outcomes, but not necessarily outcomes at 30 years.
References
1. Fischman DL, Savage MP, Welsh DV, Wilson PM, Goldberg S. Tandem stenting in the treatment of diffuse coronary atherosclerotic disease: use of multiple Palmaz-Schatz stents. J Invasive Cardiol 1989;1:264-268.
2. Sharp AS, Latib A, Ielasi A, et al. Long-term follow-up on a large cohort of “full-metal jacket” percutaneous coronary intervention procedures. Circ Cardiovasc Interv. 2009;2:416-422.
3. Kornowski R, Mehran R, Hong MK, et al. Procedural results and late clinical outcomes after placement of three or more stents in single coronary lesions. Circulation. 1998;97:1355-1361.
4. Lawrence J, Savage MP, Goldberg S, Fischman DL. The Original Coronary “Full Metal Jacket”: A 30-Year Journey. J Invasive Cardiol 2020;32(7):E186-E189.
5. Fischman DL, Leon MD, Baim DS, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med. 1994;331:496-501.
6. Aoki J, Ong AT, Rodriguez Granillo GA, et al. “Full metal jacket” (stented length ≥64 mm) using drug-eluting stents for de novo coronary artery lesions. Am Heart J. 2005;150:994-999.
7. Basavarajaiah S, Naganuma T, Lattib A, et al. Extended follow-up following “full-metal jacket” percutaneous coronary interventions with drug-eluting stents. Cathet Cardiovasc Interv. 2014;84:1042-1050.
8. Lee CW, Ahn JM, Lee JY, et al. Long-term (8 year) outcomes and predictors of major adverse cardiac events after full metal jacket drug-eluting stent implantation. Cathet Cardiovasc Interv. 2014;84:361-365.
9. Durante A, Foglia Manzillo G, Burzotta F, et al. Long term follow-up of “full metal jacket” of de novo coronary lesions with new generation zotarolimus-eluting stents. Int J Cardiol. 2016;221:1008-1012.
