Clinical Assessment, Patient Selection and Peri-procedural Care
This domain tests whether you can run an IR episode as a clinician: risk-stratify, obtain valid consent, optimise comorbidity, and manage drugs, contrast and follow-up. EBIR items often turn on a single decision - proceed, delay, or modify the plan.
Core rules
- Coagulation: for low-bleeding-risk procedures (diagnostic angiography, venous access, image-guided drainage) INR ≤1.5 and platelets ≥50 ×10⁹/L are commonly accepted. For higher-risk procedures (biliary, nephrostomy, neuro, large arterial access) aim for INR ≤1.5 and platelets ≥80 ×10⁹/L. Do not give fresh frozen plasma solely for a mildly raised INR; holding warfarin or giving vitamin K is usually better.
- Anticoagulants: stop warfarin about five days before the procedure and check INR. Hold DOACs 24–48 h depending on renal function and bleeding risk. Aspirin is usually continued; discuss dual antiplatelet therapy with cardiology.
- Renal protection: eGFR <30 - hydrate, minimise contrast, consider CO₂ or non-contrast imaging. Continue metformin if eGFR >30; hold it if eGFR <30 or there is acute kidney injury.
- Allergy: premedicate with corticosteroid plus antihistamine after a prior moderate reaction; treat breakthrough reactions with adrenaline.
- Antibiotic prophylaxis: not routine for angiography; use for biliary, nephrostomy, drainage of infected collections and prosthetic material.
Worked example
A 70-year-old man with claudication and eGFR 28 needs an angiogram. He takes apixaban for atrial fibrillation. Reasoning: this is low bleeding risk. Check INR and platelets, hold apixaban for 24 h (48 h may be needed with renal impairment), hydrate with 0.9% saline, use iso-osmolar contrast or CO₂, and limit volume. Metformin is held because eGFR <30. Consent covers contrast nephropathy and bleeding.
Traps
Reversing every anticoagulant; forgetting to recheck renal function; documenting consent before explaining alternatives; giving FFP for INR 1.6 before a venous procedure.