Section 1
Before You Take Call
Call Triage Framework
Emergent
Active hemorrhage
Hemodynamic instability, active extravasation on CT, massive GI bleed, ruptured pseudoaneurysm, post-traumatic embolization
→ In room < 30 min
Urgent
Organ threatening, stable
Acute limb ischemia (Rutherford IIa–IIb), obstructed infected biliary/urinary system, dialysis access failure with next session <24 h
→ Within 2–4 hours
Semi-Urgent
Symptomatic, stable
Drain malfunction, thrombosed non-urgent access, tube dislodgement with mature tract, non-hemorrhagic biliary obstruction
→ Morning / next slot
Info to Gather Before the Room
Every Consult
- Vitals — current and trend
- Relevant labs: CBC, CMP, coags
- Any anticoagulation? Last dose?
- Allergies (contrast, latex, antibiotics)
- Type & screen if emergent
- Imaging already available?
- NPO status — last oral intake?
- Consenting physician identified?
Before You Wake the Attending
- CT reviewed — know exactly where the bleed is
- Access established (2 large-bore IVs)
- Resuscitation active if hemorrhage
- Lab thresholds checked for procedure
- Know the patient's code status
- Anesthesia/sedation plan considered
- Have a differential — don't just say "bleeding"
When to Wake the Attending Immediately
- Active hemorrhage requiring emergent intervention
- Hemodynamic instability despite resuscitation
- Acute limb ischemia — Rutherford IIb or worse
- Stroke or new neurological change after any procedure
- Respiratory compromise during or after sedation
- Vasovagal requiring treatment (atropine, IVF)
- Any procedure you are not comfortable performing independently
- Significant post-procedure complication (pneumothorax, perforation)
- Patient refusing a procedure or changing consent
Section 2
Pre-Procedure Labs & Thresholds
SIR Bleeding Risk Categories
| Category | Bleeding Risk | Representative Procedures | INR Threshold | Platelet Threshold |
|---|---|---|---|---|
| Cat 1 | Low | Dialysis access intervention, non-tunneled CVC, paracentesis, thoracentesis, superficial aspiration, drain exchange (mature tract), PICC | No threshold | No threshold |
| Cat 2 | Moderate | Core biopsy (liver, lung, kidney), cholecystostomy, chest tube, tunneled catheter, new nephrostomy, abscess drainage, embolization | < 1.5 | > 50,000 /µL |
| Cat 3 | High | Complex biliary (PTBD, PTCS), transhepatic procedures, spinal/neuraxial, complex ablation, TIPSS, vertebroplasty | < 1.5 (mandatory) | > 50,000 /µL Some centers require >100k for neuraxial |
Hemoglobin & Contrast Thresholds
Hemoglobin
- Cat 1: no threshold — assess clinically
- Cat 2–3: generally > 8 g/dL preferred; consider T&S or crossmatch for Cat 3
- Transfuse for active hemorrhage; transfusion trigger Hgb < 7–8 g/dL in most stable patients
Iodinated Contrast & Renal Function
- eGFR > 45: contrast generally safe
- eGFR 30–45: consider pre-hydration (1 mL/kg/hr NS × 3–6 h)
- eGFR < 30: minimize volume; consider CO₂ angiography or alternative
- Dialysis: contrast OK — coordinate with renal for next session timing
- Metformin: hold 48 h post-contrast if eGFR < 60 or acute contrast exposure
Remember: These are SIR guideline thresholds, not absolute cut-offs. Factor in procedure urgency, bleeding history, correction risk, and individual patient context. Correction itself carries risk (FFP transfusion, bridging anticoagulation).
Section 3
Anticoagulation Hold Times
Based on SIR Consensus Guidelines on Periprocedural Anticoagulation. Always defer to your institution's protocol and cardiology/hematology input when relevant.
Category 2 (Moderate Risk) Hold Times
| Agent | Class | Hold Before | Resume After | Notes |
|---|---|---|---|---|
Warfarin VKA |
VKA | 5 days | Same evening / next day | Target INR <1.5; consider bridging if high-thromboembolic risk |
Heparin (UFH) |
IV anticoagulant | 4–6 hours | 1–2 h post | Check aPTT; resume at half dose if concerned |
LMWH therapeutic enoxaparin 1 mg/kg BID |
LMWH | 24 hours | 24 h post | Last dose >24 h before; check anti-Xa if concerned |
LMWH prophylactic enoxaparin 40 mg daily |
LMWH | 12 hours | Next scheduled dose | — |
Rivaroxaban Xarelto |
Factor Xa | 24 hours | Next day (24–48 h) | CrCl >50: 24 h; extend if renal impairment |
Apixaban Eliquis |
Factor Xa | 24 hours | Next day (24–48 h) | Lower accumulation risk vs. dabigatran in CKD |
Dabigatran Pradaxa |
DTI | 24–48 hours | 24–48 h post | CrCl >50: 24 h · CrCl 30–50: 48 h · Avoid if CrCl <30 |
Aspirin |
COX-1 | No hold | Continue | Continue for Cat 2; individualize if dual antiplatelet |
Clopidogrel Plavix |
P2Y12 | 5 days | 24–48 h post | Do NOT hold within 30d of BMS or 12mo of DES without cardiology |
Ticagrelor Brilinta |
P2Y12 | 5 days | 24–48 h post | Same coronary stent caution as clopidogrel |
Prasugrel Effient |
P2Y12 | 7 days | 24–48 h post | Most potent P2Y12; longest hold required |
Category 3 (High Risk) Hold Times
| Agent | Hold Before | Resume After | Notes |
|---|---|---|---|
Warfarin |
5 days | 24–48 h post | Target INR <1.5; bridge with UFH/LMWH per thrombosis risk |
Heparin (UFH) |
4–6 hours | 2–4 h post | Confirm aPTT normal; resume cautiously |
LMWH therapeutic |
24 hours | 24–48 h post | Confirm anti-Xa if concerned |
Rivaroxaban |
48 hours | 48 h post | Extend hold if CKD (CrCl <50) |
Apixaban |
48 hours | 48 h post | — |
Dabigatran |
48–96 hours | 48–72 h post | CrCl >50: 48 h · CrCl 30–50: 96 h · Avoid if CrCl <30 |
Clopidogrel / Ticagrelor |
5 days | 24–48 h post | No independent hold within stent window — cardiology sign-off required |
Aspirin (neuraxial only) |
5 days | 24–48 h post | Hold for spinal/epidural; generally continue for visceral biopsies |
Coronary Stent Rule: Never independently hold P2Y12 therapy within the dual-antiplatelet window — bare metal stent (BMS) 30 days, drug-eluting stent (DES) 12 months — without documented cardiology sign-off. Catastrophic stent thrombosis risk.
Reversal Agents
| Agent Reversed | Reversal Drug | Dose | Notes |
|---|---|---|---|
| Warfarin | Vitamin K ± 4-factor PCC (Kcentra) or FFP | Vitamin K 2.5–10 mg IV/PO 4F-PCC 25–50 units/kg per INR |
PCC fastest for urgent reversal; FFP large volume, slower |
| UFH | Protamine sulfate | 1 mg per 100 units UFH; max 50 mg | Give slowly over 10 min — risk of hypotension and bradycardia |
| LMWH | Protamine sulfate (partial) | 1 mg per 1 mg enoxaparin (last 8 h); repeat 0.5 mg/mg if needed | Only ~60–80% reversal of anti-Xa activity |
| Dabigatran | Idarucizumab (Praxbind) | 5 g IV (2 × 2.5 g vials) | Complete, rapid reversal; check renal function |
| Rivaroxaban / Apixaban | Andexanet alfa (Andexxa) or 4F-PCC off-label | Andexxa: low dose 400 mg IV bolus + 480 mg infusion; high dose 800 mg + 960 mg | 4F-PCC 25–50 units/kg used off-label if andexanet unavailable |
Section 4
Antibiotic Prophylaxis
Based on SIR Practice Parameter (Chehaib et al., JVR 2018). Always confirm with your institution's pharmacy and antibiogram. Allergy history must be reviewed before administration.
Quick Reference by Category
| Procedure | First-Line | PCN Allergy | Timing |
|---|---|---|---|
Aortic Stent-Graft / EVAR |
Cefazolin 1–2 g IV (2 g if >80 kg; 3 g if >120 kg) |
Clindamycin 600 mg IV or Vancomycin if MRSA risk |
30–60 min pre; re-dose if >4 h |
Tunneled Dialysis Catheter |
Cefazolin 1–2 g IV | Vancomycin 15 mg/kg IV | 30–60 min pre; single dose |
Percutaneous Gastrostomy (PRG) |
Ceftriaxone 1 g IV | Ciprofloxacin 400 mg IV | 30–60 min pre; single dose |
Biliary (PTBD, Cholangiogram) |
Piperacillin-tazobactam 3.375 g IV or Ceftriaxone 1 g IV + Metronidazole 500 mg |
Ciprofloxacin 400 mg IV + Metronidazole 500 mg IV |
30–60 min pre; continue if infected |
Nephrostomy / GU Procedures |
Ceftriaxone 1 g IV | Ciprofloxacin 400 mg IV or Aztreonam 1 g IV |
30–60 min pre; single dose |
Abscess Drainage |
Culture-directed Empiric: pip-tazo or ceftriaxone + metronidazole |
Ciprofloxacin + Metronidazole | Pre-drainage; continue as treatment |
Vertebroplasty / Kyphoplasty |
Cefazolin 1–2 g IV | Clindamycin 600 mg IV | 30–60 min pre; single dose |
Liver / Renal / Lung Biopsy |
Not routinely indicated | — | No routine PPx per SIR |
Diagnostic Angiography |
Not routinely indicated | — | No routine PPx per SIR |
PICC / Non-tunneled CVC |
Not routinely indicated | — | No routine PPx per SIR |
PCN Allergy Note: True IgE-mediated PCN allergy is uncommon (<1–2%). Cefazolin has a unique R1 side chain — generally safe in amoxicillin/ampicillin allergy. Vancomycin reserved for documented MRSA risk or severe PCN allergy (anaphylaxis). Skin testing preferred when time allows.
Section 5
Sedation & Analgesia
ASA Sedation Continuum
| Minimal | Moderate | Deep | General Anesthesia | |
|---|---|---|---|---|
| Responsiveness | Normal to verbal | Purposeful to verbal/tactile | Purposeful to repeated/painful | Unarousable to painful |
| Airway | Unaffected | No intervention needed | May need intervention | Often needs intervention |
| Ventilation | Unaffected | Adequate | Possibly adequate | Often inadequate |
| IR scope | ✓ Within scope — nurse-administered with physician supervision | Within scope for qualified IR; requires additional monitoring | Outside scope — anesthesiology required | |
NPO Guidelines (ASA)
Fasting Minimums — Elective
- Clear liquids → ≥ 2 hours
- Light solids / toast → ≥ 6 hours
- Fatty / heavy meals → ≥ 8 hours
- GLP-1 agonists (semaglutide, tirzepatide) → 24 h clear liquid diet, then ≥ 2 h
Anesthesiology Consult Triggers
- ASA Class V; low threshold for III–IV
- Mallampati III–IV, limited mouth opening
- Mechanically ventilated / ICU patients
- Morbid obesity or severe OSA
- Prior adverse sedation events
- Chronic opioid use; severe chronic pain
Sedation Agents
| Agent | Mechanism | Typical IR Dose | Onset | Duration | Key Hazards |
|---|---|---|---|---|---|
Propofol |
GABA-A | 1–2 mg/kg IBW infusion 10–80 mcg/kg/min |
10–50 sec | 3–10 min | ↓ SVR, hypotension, apnea at higher doses |
Dexmedetomidine |
α₂ agonist | Continuous infusion 0.2–0.7 mcg/kg/hr |
5–10 min | 1–4 h | Bradycardia, hypotension. Cooperative sedation — patient remains arousable |
Ketamine |
NMDA antagonist | 1–2 mg/kg IBW | 30 sec | 5–10 min | ↑ HR, HTN, ↑ ICP, ↑ secretions. Avoid if ↑ ICP or severe HTN |
Midazolam |
GABA-A (BZD) | 1–2 mg IV synergistic with opioids |
1–5 min | T½ 1–12 h | Amnesia, anxiolysis. Paradoxical agitation. Reduce dose in elderly |
Fentanyl |
µ-opioid | 0.5–1 mcg/kg IV | 5–10 sec | 30–60 min | Hypoventilation, chest wall rigidity (high doses). Not a sedative — use for analgesia |
Hydromorphone |
µ-opioid | 0.2–0.5 mg IV | 5 min | 3–4 h | Hepatic clearance; useful for longer procedures |
Reversal Agents
Naloxone (opioid reversal)
- 40 mcg IV; repeat q2–3 min titrate to effect
- Max 2 mg (higher doses rarely needed)
- Monitor ≥ 2 h for re-narcotization (short T½ vs. fentanyl)
- Caution: precipitates acute withdrawal and pain crisis in opioid-dependent
Flumazenil (BZD reversal)
- 0.1–0.2 mg IV q1 min; max 1 mg
- Monitor ≥ 1–2 h for re-sedation (T½ shorter than midazolam)
- Caution: seizure risk in chronic BZD users or BZD-controlled epilepsy
LAST (Local Anesthetic Systemic Toxicity): Seizures, cardiac arrest. Treatment: 20% lipid emulsion (Intralipid) 1.5 mL/kg IV bolus, then 0.25 mL/kg/min infusion. Max lidocaine 4.5 mg/kg plain, 7 mg/kg with epinephrine. Bupivacaine cardiac toxicity is most feared.
Section 6
Common Call Emergencies
🩸 GI Bleeding
- Activate massive transfusion protocol early if hemodynamically unstable — don't wait for labs
- CT angiography (arterial + portal phase) is your roadmap — get it before the table if patient is stable
- Upper GI (proximal to ligament of Treitz): endoscopy first; IR on standby or if endoscopy fails → embolize GDA, left gastric, or right gastroepiploic per CTA blush
- Lower GI: CTA localize → super-selective embolization; vasopressin infusion if no blush; avoid if ischemic colitis suspected
- No blush but unstable: empiric embolization vs. surgical consult — call your attending
- Post-embolization: check lactate, follow-up CT 48–72 h to assess for infarction
🚨 Acute Limb Ischemia
- Time-critical: 6-hour window to irreversible muscle necrosis
- Call your attending and vascular surgery simultaneously — do not delay
- Anticoagulate with UFH immediately (5,000 unit bolus) unless CI
| Rutherford | Findings | Doppler | Action |
|---|---|---|---|
| Class I Viable | No sensory or motor loss | Arterial + venous | Anticoagulate; semi-urgent imaging |
| Class IIa Marginally threatened | Minimal sensory loss, no motor | Venous signals only | Urgent revascularization (hours) |
| Class IIb Immediately threatened | Sensory + motor deficit | Often none | Emergent — OR or IR table NOW |
| Class III Irreversible | Profound deficit, mottled/rigid | None | Surgery / amputation; IR unlikely to help |
💨 Massive Hemoptysis
- Stabilize airway first — intubate affected side if unilateral (position bleeding lung down)
- CT chest for localization before bronchial artery embolization (BAE)
- 90% of hemoptysis is bronchial artery territory — left > right; common origin from T5–T6 level
- Key risk: spinal cord ischemia from anterior spinal artery arising from bronchial or intercostal arteries — identify carefully on angio before embolizing
- Technical: embolize distal to spinal artery take-off; preferred agents: PVA 300–500 µm, gelfoam; avoid coils proximally
- Recurrence rate 10–30%; etiology-directed treatment (TB, bronchiectasis, malignancy) determines long-term outcome
🩹 Post-Procedural Hemorrhage
- Track vital trends — a dropping BP over 30 minutes matters more than any single value
- Dropping Hgb >2 g/dL + hemodynamic change → escalate; get CT angiography
- Common sites: biopsy tract (hepatic, renal, lung), femoral/radial access, drain sites
- Groin pseudoaneurysm: US-guided thrombin injection (700–1,000 units in 1 mL) for most neck-bearing lesions; surgery for rapidly expanding, infected, or very wide-necked
- Access site hematoma: manual compression, reverse anticoagulation if applicable, CT if expanding
🔧 Dialysis Access Thrombosis
- AV fistula: pharmacomechanical thrombectomy — technical success lower than graft but higher long-term patency
- AV graft: easier to declot; venoplasty for outflow stenosis (most common cause)
- Urgency depends on next dialysis session — within 24 h = urgent; otherwise next available slot
- Key question before any case: does the patient have usable temporary access if you fail?
🦷 Trauma Embolization
- If the trauma team is calling you for angio, the CT has shown the bleed — review imaging en route
- Splenic: Grade III–IV with blush → angioembolization (proximal vs. selective per injury pattern); Grade V → surgery
- Pelvic fracture (hemodynamic instability): empiric bilateral internal iliac embolization even without discrete blush
- Hepatic: selective hepatic embolization; dual blood supply tolerates arterial embolization better than other solid organs
- Renal: superselective to preserve parenchyma; Grade IV–V with active bleed
Section 7
Drain & Device Troubleshooting
Drain Not Draining — Systematic Approach
- Is the drain kinked externally? Reposition before anything else
- Is the locking string intact and pigtail still deployed?
- Flush with 10 mL normal saline — does it flush freely?
- Review position on imaging — is it still within the collection?
- Collection may have changed character — loculated, too viscous, or resolved
- Consider upsizing if output drops despite good position and patency
Drain Output Changes
| Change in Output | Likely Cause | Action |
|---|---|---|
| Sudden stop | Clogged / kinked / tube migration | Flush, reposition; reimaging if fails |
| Output turns bilious | Biliary-enteric fistula or biloma tracking | Cholangiogram; external-to-internal conversion may be needed |
| Bloody output | Hemorrhage into cavity or vascular erosion by drain | CTA; escalate if large volume or hemodynamically significant |
| Suddenly very high output | Drain entered pleural space, ascites re-accumulation, or enteric fistula | CXR / cross-sectional imaging; drain repositioning vs. removal |
Nephrostomy Tube Issues
- Leaking around tube: tube malpositioned or UPJ/distal obstruction persists despite drainage
- Tube fell out: if tract mature (>4 weeks) → temporary Foley can hold tract; urgent replacement otherwise (immature tract collapses within hours)
- Hematuria persistent after nephrostomy: evaluate for AV fistula or pseudoaneurysm — CTA or selective arteriogram
- Not draining well: obstruction, kink, or distal ureteral stent dysfunction
Biliary Drain Issues
- Patient with fever post-PTBD: biliary sepsis — antibiotics immediately + verify drain patency; downgrade to external-only drainage if needed
- External drain leaking around tube: check for clogged internal side holes or persistent distal obstruction
- Tube fell out: mature tract (>4 weeks) can usually be recannulated urgently; immature tract → bile peritonitis risk — contact surgery and call your attending now
- Elevated output with pain: rule out cholangitis, tube migration into small bowel, or inadvertent biliopleural fistula
Section 8
Post-Procedure Monitoring
Arterial Access (Femoral / Radial)
- Bed rest with leg straight 2–4 h (per closure device protocol or manual hold time)
- Vitals q15 min × 1 h → q30 min × 1 h → q1 h × 2 h → per nursing judgment
- Access site checks: palpate for expanding hematoma, auscultate for bruit (pseudoaneurysm)
- Check bilateral distal pulses immediately after closure
- Pain control: local anesthetic infiltration, PO analgesics; avoid IM in anticoagulated patients
Post-Embolization Syndrome
Expected after: UFE, TACE, Y-90, splenic / renal embolization, PAE. Symptoms: fever (up to 38.5°C × 24–48 h), procedural site pain, nausea. Management: scheduled ketorolac 15–30 mg IV q6 h → then naproxen PO, antiemetics, IV hydration, opioids for breakthrough. Red flag: fever >38.5°C beyond 48 h, rigors, ↑ WBC — suspect non-target embolization or abscess; get cross-sectional imaging.
Lung Biopsy — Pneumothorax Protocol
| Size / Symptoms | Management |
|---|---|
| <15% / asymptomatic | Observation; repeat CXR in 2–4 h before discharge |
| 15–30% or symptomatic | Aspiration (14–16 Fr needle); repeat CXR; may avoid chest tube if successful |
| >30% or tension / hemodynamic compromise | Chest tube (8–14 Fr pigtail preferred in IR); emergent needle decompression for tension PTX before tube |
Biopsy Observation Minimums
Liver & Renal Biopsy
- 4–6 h bed rest post-procedure
- Vitals q1 h; serial Hgb q4 h (renal biopsy)
- Discharge if stable; CT if pain, dropping BP, or sustained tachycardia
- Monitor urine for gross hematuria after renal biopsy
Nephrostomy / Biliary Drain
- Monitor output hourly × 4 h — document volume and character
- Hematuria after nephrostomy: expected initially; frank clots or persistent blood → CTA
- Continue antibiotics per pre-procedure plan (typically 24 h)
- Review drain position on fluoroscopy image before sending patient out
Section 9
Quick Reference Numbers
Transfusion & Resuscitation
| Product | Approximate Effect | Notes |
|---|---|---|
| 1 unit pRBC | ↑ Hgb ~1 g/dL | Non-bleeding stable adult; ~250 mL volume |
| 1 unit FFP | Replaces all clotting factors | 200–250 mL; large volume for INR correction; 4F-PCC faster |
| 1 unit platelets (apheresis) | ↑ Plt ~30,000–60,000 /µL | Check 1 h post-transfusion increment if refractory |
| Massive Transfusion Protocol | 1:1:1 ratio pRBC:FFP:Plt | Activate early if >10 units pRBC anticipated in 24 h; add TXA 1 g IV within 3 h of injury |
Vasopressors & Procedural Medications
| Agent | Primary Effect | Dose | IR Use |
|---|---|---|---|
| Norepinephrine | α1 > β1 | 0.01–0.1 mcg/kg/min | First-line vasopressor in septic shock; usually managed by ICU |
| Phenylephrine | Pure α1 | 50–100 mcg IV bolus | Brief hypotension from propofol or during moderate sedation |
| Epinephrine | α + β | 0.3–0.5 mg IM (anaphylaxis) | Anaphylaxis first-line; infusion if refractory shock |
| Atropine | Antimuscarinic | 0.5–1 mg IV | Vagal bradycardia during procedure (contrast injection, wire manipulation) |
| Nitroglycerin | Venodilator | 100–200 mcg intra-arterial | Catheter-induced arterial spasm; intra-arterial admin |
Radiation Dose Reference
- Skin dose > 2 Gy: document in procedural note for follow-up
- Skin dose > 5 Gy: counsel patient about radiation injury risk; arrange dermatology follow-up at 2–4 weeks
- Skin dose > 15 Gy: deterministic injury likely; mandatory follow-up protocol
- Units: DAP (mGy·cm²) measures output; air kerma (Gy) at reference point estimates skin dose
- Scatter to staff: ~1% of patient dose at 1 m; lead apron + thyroid shield at all times
Contrast allergy breakthrough reaction: If prior allergic-like reaction to same contrast class → premedicate (prednisone 50 mg PO at 13 h, 7 h, 1 h pre; diphenhydramine 50 mg PO/IV 1 h pre). Emergency premedication if can't wait: methylprednisolone 40 mg IV or hydrocortisone 200 mg IV + diphenhydramine. Premedication reduces but does NOT eliminate reaction risk.
For deeper reference on call
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