Jan Blankensteijn, Division of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands, and principal investigator of the DREAM trial, has EVAR as his first research interest. He told Vascular News that his work includes the pathogenesis of aneurysm, advanced imaging techniques and genetic factors of aneurysmal disease. He also spoke of his career, influences, and interests outside medicine.
When did you decide you wanted a career in medicine and has it lived up to your expectations?
From an early age, I was fascinated by surgery. I remember being captivated by the first heart transplant by Dr Barnard in 1967. I did not dare think of that kind of revolution in my career. I have witnessed seemingly crazy ideas being turned into effective therapies. It is hard to describe the delight of practicing vascular surgery in this day and age. Imagine the thrill of discharging home an 80-year old patient two days after endovascular repair of a ruptured abdominal aneurysm, while having been involved with the development of this exact technique.
It fills my heart with pride to see the people that trained me, the people I have trained with, and the people that I have trained grow into amazing physicians and scientists. I continue to be inspired by people like Mark Fillinger, Michel Makaroun, Martin Malina, Ross Milner, Hence Verhagen, Geoff White, and Willem Wisselink, to name a few. These colleagues make me realise that they have not only greatly enhanced my career, but many of them also have become close friends. All of this is far beyond anything I could have imagined for a career in medicine.
Why did you decide to specialise in vascular surgery?
It was not a conscious decision. When close to completing my surgical residency in Rotterdam, I had decided that I wanted additional surgical experience in the United States. The Department of Surgery at the University Hospital in Rotterdam had collaborations with the Department of Surgery at the Massachusetts General Hospital (MGH) in Boston, MA. This helped me attain a position as clinical and research fellow at the Department of Vascular Surgery at the MGH. This year of vascular surgery training turned out to be one of the most inspiring and defining periods of my life. I always remember (and repeat to my residents) the lessons I have learned from Drs Bill Abbott, David Brewster, Rich Cambria, and Glenn LaMuraglia. They are really the ones that ignited the “vascular fire” in me. I remain grateful to them.
Which areas of vascular surgery fascinate you most?
Near the end of my term at the MGH, Dr Bill Abbott invited me to his office and handed me a current issue of the Journal of Vascular Surgery. He pointed to an advertisement with an angiogram of a large abdominal aortic aneurysm with the subtitle: “A typical case for aneurysm repair, right?” With his typical rebellious expression in his eyes, he told me to turn the page. There it read: “WRONG! A typical case for percutaneous repair”, and a rudimentary endoprosthesis had been edited in the angiogram. The advertising company was ahead of the existing technology, but I understood Dr Abbott’s message. Ever since then, I have been fascinated by endovascular techniques to replace conventional invasive vascular surgery procedures.
Vascular surgery has undergone many changes over the years – what do you think the most fundamental changes have been?
Vascular imaging. Today’s three-dimensional real-time vascular imaging seems nothing less than magic. Vascular surgeons who have been at the cutting edge of imaging development are the same physicians who have been crucial for understanding where and how the devices needed to be improved. Roy Greenberg, Mark Fillinger, Jon Matsumura, and Hence Verhagen have all excelled in aneurysm imaging research. It is not surprising to find these brilliant physicians team-up with the most innovative engineers from Cook, Cordis, Gore, and Medtronic and with ground breaking imaging companies like M2S, Philips, and TeraRecon. The most fundamental changes occur where partnership between physicians and industry operate, at the crossroads of cutting-edge imaging and out-of-the-box thinking in device technology.
Who are the people who have influenced you and what advice of theirs do you always remember?
This list is long, and continues to grow. My first teacher in surgery, Prof van Vroonhoven inspired me in many ways. His most important lesson for me as a surgeon was probably to stay humble. The day a surgeon believes he can achieve anything is the day he becomes a threat to his patients. My later mentor Prof Hero van Urk taught me to never settle for anything less than the best. At the end of every operation, I still find myself closely evaluating myself (and residents) about all aspects of the procedure. Prof Eikelboom, a visionary man who implanted the first human endograft (EVT) in Europe, in January 1994, hired me at the University Medical Center of Utrecht and allowed me to make endovascular aneurysm repair my project. He is the one who taught me to always challenge the new and exciting and prove it with scientific rigor. In this way, he inspired me to organise the DREAM trial. Apart from these founding fathers of vascular surgery in The Netherlands, I consider Roger Greenhalgh and Frank Veith as my most inspiring vascular surgery role models. They are passionate about cutting-edge therapies and equipped with relentlessly inquisitive minds.
I also continue to be influenced by contemporary and younger colleagues like my current partner in the department of vascular surgery in Amsterdam, Willem Wisselink – the first to file a patent on side-branched endografts. He has a wealth of preclinical data on side-branch technology and never stops astounding me with his thought-provoking ideas; Mark Fillinger, a partner in many of our imaging studies, always seems to be one step ahead of me with imaging research; and Martin Malina, David Minion and Eric Verhoeven who drive the existing device technology beyond the boundaries of what is considered possible, fueling device evolution.
What are your current areas of research?
EVAR is my primary interest. We are finalising the seven year analyses of the DREAM trial cohort. My basic research focuses on unravelling the pathogenesis of aneurysm and trying to improve patient selection using advanced imaging techniques (like PET-CT) and on identifying genetic factors of aneurysmal disease. I believe we are still at the beginning of understanding vascular disease and I am excited about the new areas of vascular research and device technology emerging. I can see a whole host of young motivated vascular surgeons stepping up to explore unchartered territories. I feel privileged being able to do research in an era with such great opportunities around the corner.
How do you analyse the findings of the DREAM and DREAM-ON trials so far?
Together with EVAR-1 and OVER, these trials indicate that there is an advantage of EVAR over open repair in the short-term, while the results are not different in the long run, thus EVAR is the better option. There are still many questions remaining that can only be answered by merging the trial data at the individual patient level. I cannot wait to cooperate with Drs Greenhalgh, Lederle, and Becquemin to get that project off the ground. Now that the long-term results of the DREAM trial have been published, it is appropriate to note that we have been fortunate to have had three New England Journal of Medicine publications out of this “small country” trial. I would like to emphasise that none of this would have been possible without the Dutch and Belgian participants. I would like to sincerely thank them for their diligent involvement.
You have developed some medical software along your career. How did this start and which applications you consider most useful?
When I started surgical training, personal computers had just arrived and there were few applications for researchers available. This is when I started making applications for patient databases and statistical analysis. Later in my career, I continued using a combination of understanding patient logistics and the ability to manipulate computers and software to design applications for instance to assist in the complex follow-up schemes of EVAR, and to support multidisciplinary meetings.
You developed your career in The Netherlands but also have had experience in the USA. What have you learnt from it?
My experience in the USA is from almost two decades ago and things have changed significantly on both sides of the Atlantic. However, despite the obvious big differences in healthcare between the USA and the Netherlands, once you get down to the basics of surgery, things are always remarkably similar and operator-dependent.
Outside of medicine and computer programming, what other interests do you have?
My wife will laugh when she reads this, because she feels there is little that interests me besides these two. I like to spend time with my loved ones, travel, and visit museums, concert-halls, and theatres. We all love nature, hiking, skiing, and snowboarding. I also have a passion for music, both passive and active. Whenever I get a chance I play my electric guitar.
1977–1984 Medical School, University of Utrecht, The Netherlands
1984–1985 Resident in Surgery, St Elisabeth Hospital, Tilburg, The Netherlands
1985 Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) and ECFMG English Test
1985–1986 Resident Surgery, St Maartensgasthuis, Venlo, The Netherlands.
1986–1989 Resident Surgery, University Hospital “Dijkzigt”, Rotterdam, The Netherlands
1988 Course on Microsurgery, Laboratory for Surgical Research, Erasmus University, Rotterdam
1989–1992 Resident Surgery, Zuiderziekenhuis, Rotterdam
1992 PhD Thesis: “Orthotopic and Heterotopic Liver Transplantation. Circulatory and hemodynamic effects of long-term graft preservation”, Erasmus University
1992–1993 Clinical fellow Vascular Surgery, Massachusetts General Hospital, Boston, USA
1993–1994 Department of Vascular Surgery, University Hospital “Dijkzigt”
1994–2003 Division of Vascular Surgery, Department of Surgery, University Hospital Utrecht
2003–2008 Division of Vascular Surgery, Radboud University Nijmegen Medical Centre, The Netherlands
2009–Present Division of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands
The Netherlands Society for Surgery (1985–Present), The Netherlands Society for Vascular Surgery (1993–Present), The Netherlands Society for Vascular Medicine (1993–Present), European Society for Vascular Surgery (1993–Present), International Society for Endovascular Specialists (1994–Present), Dutch Endovascular Forum (1996–2001), Society for Vascular Surgery (2002–Present; 2003 Distinguished Fellow), International Society for Vascular Surgery (2004–Present, founding member)
Positions at professional societies, committees and organisations
President of the Dutch Endovascular Forum (1996–2003), Secretary of The Netherlands Society for Vascular Surgery (1998–2002), Ad Hoc Committee on Reporting Standards of the Society for Vascular Surgery and the American Association of Vascular Surgeons (1999–2001), member UEMS-VASC/European Board of Vascular Surgery (2003–current), chairman Vascular Surgery Certification Committee (2004–2006).
Positions at peer-reviewed scientific journals
Editorial secretariat Journal of Cardiovascular Surgery, editorial board Journal of Endovascular Therapy, editorial board Journal of Vascular Surgery (2004–2008), associate editor Vascular, associate editor Journal of Vascular Surgery, publications committee Journal of Endovascular Therapy.
2002 Department of Vascular Surgery, Royal Prince Alfred Hospital Sydney, Australia
2003 Division of Vascular Surgery, Emory University Atlanta, USA, Ross Milner
2003 Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania Health System, Philadelphia, USA
2006 Division of Vascular Surgery, University of Pittsburgh School of Medicine, USA, Michael S Makaroun