Early and Midterm Results of Stent Endarterectomy for Left Anterior Descending Coronary Artery “Full Metal Jacket”


  • Rafik F. B. Soliman, MD, FRCS (Eng, CTH) Cardiothoracic Surgery Department Faculty of Medicine, Menoufia University, Menoufia, Egypt
  • Sunil Ohri, MB BS MD FRCS (Eng, Ed & CTH) FESC Cardiac Surgery Department, Southampton University Hospital, Southampton, UK
  • Mohamed Hagag, MD Cardiothoracic Surgery Department Faculty of Medicine, Menoufia University, Menoufia, Egypt
  • Fouad M Rasekh, MD Cardiothoracic Surgery Department, Faculty of Medicine, Cairo University, Cairo, Egypt




stent endarterectomy, LAD metal Jacket, coronary artery bypass grafting, Graft patency, Follow-up results


Objective: Modern coronary interventional practice can result in coronary vessels that are totally stented. The term “full metal jacket” has been coined to refer to vessels that have an overlapping stent in series along the whole length of the vessel. This poses a serious challenge to surgical revascularization, particularly when a left internal thoracic artery (LITA) to the left anterior descending (LAD) needs to be undertaken. We evaluated the early and midterm results of on-pump coronary artery bypass grafting (CABG) following “stent endarterectomy” for the LAD with LITA to LAD grafting.

Methods: During October 2017 to September 2020, 21 patients presented with multi-vessel disease and a totally occluded LAD with a stent full metal jacket. No distal target for LITA grafting was available, despite a viable myocardial territory. The LAD was endarterectomised, removing the column of totally occluded stents with the medial wall of the vessel, leaving the proximal stent in place to avoid competitive flow. Long length anastomosis was then undertaken with the LITA graft. Postoperatively, patients were followed up clinically and by coronary computed tomography (CT) angiography at 6- and 18-month intervals. All patients were discharged on a combination of aspirin and warfarin for three months and then aspirin and clopidogrel for the rest of the first year and then aspirin alone for life.

Results: Patients had a mean age of 58.07 ± 2.06 yr. Sixteen (76.2%) were males, 13 (61.9%) patients were diabetics, 18 (85.7%) were hypertensive, 15 (71.4%) were dyslipidemic, six (28.6%) were obese, 11 (52.4%) were smokers, and five (23.8%) had positive family history of ischemic heart disease (IHD). The number of grafts per patient ranged 3-5, with a mean cross-clamp time of 64.71± 8.84 min. There were no postoperative deaths nor MI clinically, by electrocardiogram (ECG) criteria nor by troponin or CK-MB. In-hospital complications included one (4.8%) patient who required re-exploration for bleeding, one (4.8%) developed a superficial wound, and three (14.3%) developed atrial fibrillation (AF), during their hospital stay. Mean hospital stay was 7.71±1.73 days. All patients completed the 6-month follow up showing patent LITA to LAD with coronary CT angiography. One patient was lost to follow up after six months; five patients are awaiting their 18-month CT angiography, while 15 (71.4%) patients have completed their 18-month CT angiography, and all have a patent LITA to LAD.

Conclusions: Stent endarterectomy for a totally occluded LAD with a full metal jacket and viable myocardial territory is a safe procedure with good early and midterm results. This technique should be considered in these difficult cases presenting for revascularisation when no other option is available.

Author Biography

Rafik F. B. Soliman, MD, FRCS (Eng, CTH), Cardiothoracic Surgery Department Faculty of Medicine, Menoufia University, Menoufia, Egypt

Associate professor and Head of Cardiothoracic Surgery department


Aoki J, Ong AT, Rodriguez Granillo GA, McFadden EP, van Mieghem CA, Valgimigli M, et al. 2005. "Full metal jacket" (stented length > or =64 mm) using drug-eluting stents for de novo coronary artery lesions. Am Heart J. 150(5):994-9.

Bailey CP, May A, Lemmon WM. 1957. Survival after coronary endarterectomy in man. J Am Med Assoc. 164(6):641-6.

Beretta L, Lemma M, Vanelli P, DiMattia D, Bozzi G, Broso P, et al. 1992. Coronary "open" endarterectomy and reconstruction: short- and long-term results of the revascularization with saphenous vein versus IMA-graft. Eur J Cardiothorac Surg. 6(7):382-6; discussion 7.

Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R. 2010. In-stent restenosis in the drug-eluting stent era. J Am Coll Cardiol. 56(23):1897-907.

Demir T, Egrenoglu MU, Tanrikulu N, Cizgici AY, Yildirim KI, Dindar I, et al. 2015. Surgical Revascularization of the Left Anterior Descending Artery with Multiple Failed Overlapping Stents. J Card Surg. 30(12):877-80.

Demirsoy E, Tandogan A, Yilmaz O, Tukenmez F, Tufekcioglu S, Sonmez B. 2006. Grafting the restenosed coronary artery after removal of multiple failed stents by endarterectomy. Tex Heart Inst J. 33(2):262-3.

Effler DB, Groves LK, Sones FM, Jr., Shirey EK. 1964. Endarterectomy in the Treatment of Coronary Artery Disease. J Thorac Cardiovasc Surg. 47:98-108.

Eryilmaz S, Inan MB, Eren NT, Yazicioglu L, Corapcioğlu T, Akalin H. 2003. Coronary endarterectomy with off-pump coronary artery bypass surgery. The Annals of Thoracic Surgery. 75(3):865-9.

Filippone G, Calia C, Vacirca SR, Caruana G, Re MR, Giardina C, et al. 2018. Coronary endarterectomy to facilitate bypass surgery for patients with extensive stenting of the left anterior descending artery. Coron Artery Dis. 29(4):359-60.

Fukui T, Takanashi S, Hosoda Y. 2005. Coronary endarterectomy and stent removal in patients with in-stent restenosis. Ann Thorac Surg. 79(2):558-63; discussion 63.

Fundarò P, Di Biasi P, Santoli C. 1987. Coronary endarterectomy combined with vein patch reconstruction and internal mammary artery grafting: experience with 18 patients. Tex Heart Inst J. 14(4):389-94.

Hoffmann R, Mintz GS. 2000. Coronary in-stent restenosis - predictors, treatment and prevention. Eur Heart J. 21(21):1739-49.

Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, et al. 2013. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. Eur J Cardiothorac Surg. 43(5):1006-13.

Keogh BE, Bidstrup BP, Taylor KM, Sapsford RN. 1991. Angioscopic evaluation of intravascular morphology after coronary endarterectomy. Ann Thorac Surg. 52(4):766-71; discussion 71-2.

Kleisli T, Cheng W, Jacobs MJ, Mirocha J, Derobertis MA, Kass RM, et al. 2005. In the current era, complete revascularization improves survival after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 129(6):1283-91.

Kobayashi Y, De Gregorio J, Kobayashi N, Akiyama T, Reimers B, Finci L, et al. 1999. Stented segment length as an independent predictor of restenosis. J Am Coll Cardiol. 34(3):651-9.

Myers PO, Tabata M, Shekar PS, Couper GS, Khalpey ZI, Aranki SF. 2012. Extensive endarterectomy and reconstruction of the left anterior descending artery: early and late outcomes. J Thorac Cardiovasc Surg. 143(6):1336-40.

Nishi H, Miyamoto S, Takanashi S, Minamimura H, Ishikawa T, Kato Y, et al. 2005. Optimal method of coronary endarterectomy for diffusely diseased coronary arteries. Ann Thorac Surg. 79(3):846-52; discussion 52-3.

Nishigawa K, Fukui T, Takanashi S. 2015. Off-pump coronary endarterectomy with stent removal for in-stent restenosis in the left anterior descending artery. Interact Cardiovasc Thorac Surg. 21(5):594-7.

Shapira N, Lumia FJ, Gottdiener JS, Germon P, Lemole GM. 1988. Adjunct endarterectomy of the left anterior descending coronary artery. Ann Thorac Surg. 46(3):289-96.

Shapira OM, Akopian G, Hussain A, Adelstein M, Lazar HL, Aldea GS, et al. 1999. Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy. Ann Thorac Surg. 68(6):2273-8.

Sommerhaug RG, Wolfe SF, Reid DA, Lindsey DE. 1990. Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease. Am J Cardiol. 66(7):651-9.

Srimurugan B, Sigler M, Sankar NM, Cherian KM. 2018. In-stent restenosis: surgical and histopathological perspective. 26(2):114-9.

Tiruvoipati R, Loubani M, Lencioni M, Ghosh S, Jones PW, Patel RL. 2005. Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery. Ann Thorac Surg. 79(6):1999-2003.

Tiruvoipati R, Loubani M, Peek G. 2005. Coronary endarterectomy in the current era. Curr Opin Cardiol. 20(6):517-20.

Tsagalou E, Chieffo A, Iakovou I, Ge L, Sangiorgi GM, Corvaja N, et al. 2005. Multiple overlapping drug-eluting stents to treat diffuse disease of the left anterior descending coronary artery. J Am Coll Cardiol. 45(10):1570-3.

Uchimuro T, Fukui T, Mihara W, Takanashi S. 2009. Acute thrombosis after endarterectomy of stented left anterior descending artery. Interact Cardiovasc Thorac Surg. 8(6):663-5.

Yilmazkaya B, Circi R, Circi UP, Gurkahraman S, Yukselen MA, Yondem OZ, et al. 2008. Surgical approaches in left anterior descending artery in-stent stenosis. Ann Thorac Surg. 85(5):1586-90.

Zattera GF, Grande AM, Gaeta R, Savasta M, Lentini S, Viganò M. 2010. Reconstruction of anterior descending artery after removal of stents. Asian Cardiovasc Thorac Ann. 18(3):291-3.



How to Cite

Soliman, R., Ohri, S., Hagag, M., & Rasekh, F. (2021). Early and Midterm Results of Stent Endarterectomy for Left Anterior Descending Coronary Artery “Full Metal Jacket”. The Heart Surgery Forum, 24(3), E467-E473. https://doi.org/10.1532/hsf.3805