Martin Björck, professor of Vascular Surgery, Institution of Surgical Sciences, Department of Vascular Surgery, Uppsala University Hospital, Sweden, holds the only professor-chair of vascular surgery position in Sweden. A strong advocate of abdominal aortic aneurysm screening programmes, Björck has been at the forefront of the Swedish experience in identifying men over 65 years of age at risk of aneurysm rupture. He tells Vascular News about his early career, proudest moment and hobbies, including moose hunting, hiking and cooking.
When did you decide you wanted a career in medicine and in particular, why did you choose vascular surgery?
I had an international upbringing, living in India, Iran and Iraq as a child. My early interest in medicine was guided by an interest to practise medicine in developing countries. On my way to serve in the newly independent southern African nations Angola and Mozambique I realised I needed surgical training. During war-time surgery, and later when I returned to Sweden, I observed that the only situation in which well-trained surgeons lost control was during major haemorrhage. I trained in vascular surgery to be able to stay in control, but enjoyed it so much that it became my speciality.
Who has inspired you in your career and what advice of theirs do you remember today?
My first inspiration was my mother, who was a nurse. She was hard-working and claimed she never experienced a single dull working-day. My first surgical tutor was Arne Kjellgren, an excellent surgeon, technically speaking, and with an extraordinary ability to meet the suffering patient. He taught me empathy, to listen to the patient, and to examine and operate with meticulous detail. My tutors in vascular surgery were Bengt Hedberg in Umeå and Prof David Bergqvist in Uppsala. David was my tutor in science as well. He taught me dedication to detail, in both surgery and science.
During your career, what have been your proudest moments?
I never did anything alone, it has been always a team effort, but building that team is probably my main achievement. The following moments felt particularly good: 1) When my first two PhD students Anders Wanhainen and Stefan Acosta defended their theses, a public event in Sweden, and when later they both became successful academic vascular surgeons; 2) Starting the Swedish abdominal aortic aneurysm screening programme in Uppsala together with Anders in 2006, and observing that in only 5–6 years, all of Sweden followed; 3) Replacing David Bergqvist as the only full professor of vascular surgery (chair) in Sweden in 2008; and 4) The creation of a distance learning course in vascular surgery in 2002 became a great success, and I was given the task to organise training on a national level in 2008.
How has vascular surgery evolved since you began your career?
In Sweden we used to be a subspecialty of general surgery. In 2006 we became a branch specialty, and in 2015 we will become a monospecialty. The endovascular revolution was initiated by innovative radiologists in Sweden, such as Sven-Ivar Seldinger, but soon this minimally invasive technique was embraced by vascular surgeons. This is an important development, from imaging-focused interventional radiology towards patient-oriented endovascular surgery. It also results in great demands in training, since you need to master clinical know-how as well as both open and endovascular techniques.
What have been your most memorable clinical cases?
I was the only vascular surgeon in Skellefteå, a hospital in the scarcely inhabited northern region, and the population had high prevalences of aneurysms and other vascular diseases. Those were nine tough years with many demanding cases, day and night. A man with vascular Ehlers-Danlos’ syndrome, who I treated for a ruptured abdominal aortic aneurysm, was maybe the toughest challenge. The fact that he survived with a favourable outcome makes this case even more memorable. After having moved to Uppsala in 2001 I have had many difficult carotid body tumours, reaching to the base of the scull. I receive referrals from all over Scandinavia for this condition. Offering these young patients a multidisciplinary team to minimise post-operative morbidity has been very rewarding.
Screening for abdominal aortic aneurysms is one of your interests. In your view, why is screening important?
When I worked in the north we had a great case-load of ruptured aneurysms. Thanks to a great team effort with anaesthesiologists and intensivists we managed to reduce the mortality after ruptured aneurysms to only 16%. We did also have a high autopsy rate; however, explained by a research interest in cancer epidemiology and cardiology. It made me realise that we were only seeing the tip of the iceberg. Most patients with ruptured aneurysms never reached the hospital. This was the rationale for performing the first population-based abdominal aortic aneurysm screening in Sweden in 1999, and following the path of those who evaluated aneurysm screening in the UK, Denmark and West Australia.
What do you think a comprehensive screening programme should involve?
Inviting all 65-year-old men is very practical and straightforward, although strictly speaking this design of abdominal aortic aneurysm screening was never evaluated in a randomised trial. We have data that suggest that it may not be safe to leave those with an aortic diameter above 24mm without follow-up. The issue of whether smoking women should be included is controversial. Smoking cessation and secondary prevention are important components.
How can other countries replicate the Swedish experience with screening?
I am sure many will follow the UK and Sweden in creating national screening programmes. After all, this is the only way to effectively reduce the mortality from aneurysm rupture. In our experience we were astonished how relatively easy it was to organise the programme, how quickly you could screen a person (it only takes us four minutes), and how well it was received by the population.
What are the key unanswered questions in the management of abdominal aortic aneurysms?
The changing epidemiology transforms aneurysm screening into a moving target. When the population smokes less and lives longer they may need screening and repair later in life. Another issue of great importance is to try to distinguish healthy from diseased people among those with an aortic diameter 25–35mm. It is also important to follow the development of the disease among smoking women.
The issue of how to measure the aorta is crucial, and we need a consensus. To develop the optimal medical treatment to prevent aneurysm growth and cardiovascular events is also important, to offer the maximum benefit to the patients.
You are a member of the World Society of the Abdominal Compartment Syndrome (WSACS). The syndrome has gone from being something seen as imaginary to one that is recognised as being a serious condition. What have been the other developments in how we understand the condition?
The first step was to recognise the problem, and this is achieved in most places. The second step was how to manage patients with the syndrome. Here we have also had success in the development of new algorithms and adjunctive procedures, such as the VAC with mesh mediated fascial traction, to enable early closure. The third step, which maybe should have been the first, is how to prevent abdominal compartment syndrome. Here we were assisted by the experiences in the wars in Iraq and Afghanistan, where it was shown so elegantly that whole blood resuscitation makes a great difference. The short version is: “If the patient bleeds crystalloids, give crystalloids, but if he/she bleeds blood, give blood!”
The WSACS guidelines were published last year. What were their key recommendations?
The importance of classification of the open abdomen was recognised. There are no data that support prophylactic open abdomen, but a wealth of data suggest that protocolised monitoring of intra-abdominal pressure in patients at risk of developing abdominal compartment syndrome makes a difference. Strategies utilising negative pressure wound therapy should be used, versus not, and preventing lateralisation of the abdominal wall is important. Both enhance early closure, which prevents complications.
What are your current research interests?
We are currently performing a randomised trial to evaluate the potential of preventing growth of small abdominal aortic aneurysm with the new platelet inhibitor ticagrelor, which seems to have no non-responders. Anders Wanhainen is the principal investigator of this trial. We have many research projects regarding aneurysm screening, and if we could offer an effective drug therapy to prevent growth of small aneurysms that would add benefit to the programme. The development of a more effective smoking cessation programme is also underway. We have a great interest in popliteal, thoracic and thoracoabdominal aneurysms, as well as in vascular trauma and intestinal ischaemia.
What is the most interesting paper you have come across recently?
The IMPROVE trial is a great paper, both the paper in BMJ and the cohort study published in the BJS. People who criticise this trial are not aware of the difficulties in performing research in emergency patients. If it had not been for the unfortunate new Swedish law that requires informed consent without exception, we would have participated in the trial. I am working on trying to change that law, actually with good chances of success.
What advice would you give to a vascular surgeon just starting their career?
The early advice would be to focus on learning to know the patients and the diseases, rather than the technology of treatment, and to keep the patient focus throughout your career.
To combine innovation with scientific evaluation, and to collaborate with industry, but maintain independence are the keys to academic success. There are so many examples of new technology that have never been properly evaluated. Embrace the new endovascular technology, but with a critical thinking. Make sure that you have a good training in both open and endovascular surgery, and in science!
And last but not least, take care of your family. That is what counts most in the end.
Outside of medicine, what are your interests?
I am very fond of nature, and concerned about how we treat our planet. Moose hunting, mushroom picking, hiking in the mountains, as well as biking, are all great to rinse your body and mind. My son hunts with me, which adds pleasure. I enjoy cooking too, and not only the moose. I have a small piece of forest that I “take care of” with the chainsaw, and an old farmstead that needs some attention. I enjoy books, film and theatre—afterall Ingmar Bergman was born and raised here in Uppsala.
Professor of Vascular Surgery, Institution of Surgical Sciences, Department of Vascular Surgery, Uppsala University Hospital, Sweden
1978 Medical doctor, examination
1990 Specialist in Surgery, examination
1998 Dissertation for PhD: On intestinal ischaemia after aortoiliac surgery, Epidemiological, clinical and experimental studies, Uppsala University
1992 Consultant in vascular surgery
2000– Consultant in vascular surgery, Uppsala University Hospital
2002 Associate professor, Vascular Surgery, University of Uppsala
1999–2002 Editor of the Journal Svensk Kirurgi (Swedish Surgery)
2003–2009 Co-editor of the Journal Svensk Kirurgi (Swedish Surgery)
2008– Professor chair of Vascular Surgery, Uppsala
2012– Associate editor, European Journal of Vascular and Endovascular Surgery
1997–2001 and 2008-2012 Board member of the Swedish Society for Vascular Surgery
1999–2002 Board member of the Swedish Surgical Society
1999–2007 Board member of SWEDVASC (Swedish Vascular Registry)
2002–2007 Chairman of SWEDVASC (Swedish Vascular Registry)
1997– Board member of Vascunet
2003–2006 Chairman of Vascunet
2001–2005 Member of the Educational Committee of Scandinavian Association of Vascular Surgery
2003–2005 Chairman of the Education Committee, SAVS
2005– Member of the International Surgical Group
2008–2012 National Director of Training in Vascular Surgery
2009– Consultant to the National Board of Health and Welfare
2011–2014 Councillor of the European Society for Vascular Surgery
2014– Member, Ethical committee of the Swedish Research Council
1998 Swedish Vascular Award
2003 The Acrel Medal (Most distinguished award of the Swedish Surgical Society)
2011 Surgical educator of the year (Swedish Surgical Society)
- Publication of 160 original articles and 80 review articles and book chapters
- Supervisor of seven PhD students who completed their thesis and another 14 are underway
- Member of editorial boards: British Journal of Surgery, European Journal of Vascular and Endovascular Surgery, World Journal of Surgery, Scandinavian Journal of Surgery, Angiologia e Cirurgia Vascular, and Pan Arab Angiology Journal