Babak Alex Vakili: The Evolution of Coronary Stents and Antithrombotic Therapy
Babak Alex Vakili, President and CEO at Heart Vein and Vascular Clinic, shared on LinkedIn:
”I’ve been doing coronary and peripheral vascular interventions since the late 1990s, so I’ve lived through every major phase of PCI. I started in the balloon angioplasty and bare-metal stent era, transitioned through first-generation drug-eluting stents (BX Velocity), and now practice in the era of modern DES and refined antithrombotic strategies. Many of the changes we see today simply confirm what hands-on experience taught us years ago.
Plain balloon angioplasty failed because of recoil and dissection. Bare-metal stents solved acute closure but introduced restenosis as a dominant problem. When first-generation DES arrived, restenosis dropped dramatically, but we quickly learned the tradeoff: late and very-late stent thrombosis. Thick struts, rigid stainless-steel platforms, and bioincompatible polymers mattered, even if we didn’t fully understand why at the time. Clinically, we saw it.
Modern DES are fundamentally different devices. Thinner struts made possible by cobalt- and platinum-chromium alloys are not just engineering improvements, they translate into less thrombosis, better deliverability, and fewer side-branch issues. Polymer technology has matured, whether biocompatible, bioresorbable, or eliminated entirely, and limus-based drugs clearly outperform paclitaxel in terms of healing and safety. Ultra-thin strut stents further improve endothelialization, though in my experience they require respect in complex anatomy where recoil can still matter.
Equally important, how we deploy stents has evolved. Early in my career, angiography alone guided most decisions. Today, we understand that underexpansion, malapposition, and edge disease drive failure. Intravascular imaging has validated what many of us suspected clinically: optimal sizing, lesion preparation, and post-dilatation matter as much as the stent itself.
Antithrombotic therapy has followed a similar arc. We relied on aspirin alone, then dual antiplatelet therapy, and later recognized the limitations of clopidogrel. More reliable P2Y12 inhibition with prasugrel and ticagrelor has reduced ischemic events, while bleeding has emerged as a complication with prognostic weight similar to myocardial infarction. With safer stents, better deployment, and aggressive risk-factor control, earlier de-escalation of DAPT is now often appropriate, something that would have been unthinkable in the early DES era.
For those interested, here’s a well-written review that nicely summarizes many of these changes and where the field is heading.”
Article: Evolution of coronary stents: innovations, antithrombotic strategies and future directions
Authors: William A E Parker
Read full review here.
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