“He aha te mea nui o te ao? He tāngata, He tāngata, He tāngata,” said Andrew Holden (Auckland City Hospital, Auckland, New Zealand), quoting a Māori phrase to open his Charles T Dotter Lecture at the 2026 Society of Interventional Radiology (SIR) annual scientific meeting (11–15 April, Toronto, Canada). The phrase asks: What is the most important thing in the world? It is people, it is people, it is people—and embodies the most important aspect of Holden’s path in interventional radiology (IR). In this interview, Holden reflects on what his lecture, titled ‘Interventional radiology: A journey of creativity’, sought to convey.
What is meant by ‘a journey of creativity’?
Through IR, I fell into a more academic role and that’s really what my Dotter Lecture was about: a journey of creativity. People often associate creativity with the arts, but scientists and doctors can be just as creative if they’re able to see solutions to problems that other people haven’t recognised. For me, that became the challenge. I identified areas where I didn’t think we were performing particularly well in IR, attended meetings, saw people trying new approaches, and came away with a few ideas of my own.
It was a time when it was somewhat easier to innovate before all of the regulatory requirements associated with formal clinical trials had developed to the extent they have today. That gave me a real taste of making a difference through innovation and being creative.
From there, things gradually gathered momentum. Quite early on, I realised that Auckland was never going to compete with the world’s largest academic centres on volume alone—we simply didn’t have the same number of patients. Instead, we made a conscious decision that our strength would be in being among the first to evaluate new technologies. That became our niche, assessing new devices early, providing valuable feedback and helping to develop technologies that ultimately benefit patients around the world.
Multidisciplinary working was one of the central themes of your lecture. What does that look like in your day-to-day practice?
Where I trained, multidisciplinary working was the norm, and I could immediately see the benefit, particularly for patients. Whenever I’ve worked in environments where patients weren’t placed first and specialties operated more independently, I’ve generally seen poorer practice and poorer outcomes.
Today, multidisciplinary meetings are fundamental to everything we do. Every patient’s imaging, clinical presentation and pathology are reviewed collectively, and management decisions are reached by consensus. Beyond that, we recognise there is considerable overlap between IR and other specialties. Particularly in complex vascular disease, we recognise that there is a crossover in expertise and training between IR and vascular surgery—we need to work hand-in-hand. Interventional radiologists are strong on procedural aspects, but during training, we need a greater emphasis on clinical practice and managing patients. Conversely, almost the opposite is true of vascular surgeons who have strong clinical skills but may lack endovascular expertise.
During your talk you presented an audit showing an increase in lower limb interventions in the last 20 years. What is driving that change?
Vascular specialists of a similar vintage to me will have definitely seen a striking change in the patient population and the Dotter Lecture was an opportunity to ask exactly that question: Is this true and why is it happening?
We compared our practice over two years separated by two decades (2005 and 2025), and the differences were dramatic. Not only were we performing significantly more procedures for a similar population, but the patients themselves had changed. Twenty years ago, many patients were referred with intermittent claudication or pain on walking. Today, while we still see those patients, virtually all of the growth has been in people presenting with chronic limb-threatening ischaemia (CLTI).
The pattern of disease has also evolved. Twenty years ago disease was predominantly affecting the iliac and femoral arteries. Those vessels are still commonly involved, but we now see far more disease extending into the arteries below the knee and into the foot.
What’s driving that? We’re increasingly able to answer this question, even down to the cellular level. Although there are genetic factors, the biggest drivers are environmental and metabolic. Smoking still plays an important role, but obesity, diabetes and renal disease have become much more significant contributors. These conditions produce changes within the endothelium, platelets and smooth muscle cells that ultimately alter the biology of the arterial wall; one of the most important consequences is vascular calcification. Twenty years ago, heavily calcified arteries were relatively uncommon, but today, they’re present in the vast majority of patients we treat.
That’s one reason why technologies specifically designed to modify or treat calcium have become so important. They’re addressing an unmet need because our older technologies do not manage calcific arterial disease well. It’s encouraging that we are no longer just observing the change in distribution and severity of vascular disease, we’re understanding the biological mechanisms behind it.
You’ve spoken about the importance of being a clinician rather than a proceduralist. How does that philosophy shape your own practice?
Essentially, it means building a practice around patients and clinics rather than procedures. That clinical involvement is critical. We see patients before intervention, manage them during their hospital admission and continue to follow them afterwards. That’s what being a vascular specialist means, and of course, IR extends well beyond vascular disease.
Increasingly, we’re seeing some overlap between specialties, for example a vascular specialist might be a vascular surgeon with excellent endovascular skills, or an interventional radiologist with strong clinical expertise. Likewise, an interventional oncologist may be an interventional radiologist with specialist oncology knowledge, but in some centres oncologists themselves are developing interventional skills.
For me, the future is about combining technical skills with clinical care. For our trainees, they are required to do a significant amount of clinic work in their training, so that they are comfortable with the clinical management of the patients they treat.
