Medical Licensing (MD/DO) · Independent exam preparation
EBIR Preparation Guide: Clinical Decisions Across Six Domains Study Guide
Practise patient selection, procedural planning and complication management across all six EBIR domains with 60 focused concepts, clinical cases and recall drills.
By CertMedbry · Updated 19 October 2026
Practise deciding who benefits from intervention, choosing a safe treatment route, recognising complications and evaluating outcomes. These 60 selected concepts connect mechanisms with clinical decisions across all six EBIR domains. The full European Curriculum and Syllabus for Interventional Radiology, Third Edition, remains the complete scope reference; this guide supports focused review rather than exhaustive syllabus coverage.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which examination and certification level does this guide address?
This guide addresses the general European Board of Interventional Radiology examination administered by CIRSE for interventional radiologists. It assesses clinical and technical knowledge relevant to safe IR practice. It is voluntary supplemental certification with international availability; national authorities retain responsibility for training recognition and licensing.
Which blueprint edition applies, and from when?
CIRSE identifies the February 2023 third edition of the European Curriculum and Syllabus for Interventional Radiology as the basis for EBIR examinations from March 2024 onward. The 2013 and 2017 editions are historical predecessors.
CIRSE — Curricula · European Curriculum and Syllabus for Interventional Radiology — Third Edition
Are official domain percentages published?
The official blueprint provides qualitative frequency categories rather than percentage weights. Green topics appear in almost every examination, yellow in most examinations, red rarely, and purple competencies are verified through the competency checklist. This guide's educational allocation is 12 fundamental, 18 vascular, 10 chest/GI/hepatobiliary, 7 genito-urinary, 5 musculoskeletal and 8 oncology concepts. It is not an official weighting.
European Curriculum and Syllabus for Interventional Radiology — Third Edition
What are the question count, scored/pretest split and examination duration?
CIRSE describes an assessment lasting approximately four hours with a 30-minute break between its two sections. The clinical case section contains 10 sequential cases, each with 4–6 questions, approximately 50 case questions overall. The general clinical practice section contains approximately 50 standalone single-best-answer questions. Case questions can require a single answer, multiple correct answers or placing responses in order. A separate scored/pretest split is not confirmed in these documents.
How is EBIR delivered, and is it adaptive?
CIRSE describes EBIR as a fully remote examination with two annual examination opportunities. The current issuer page lists English, German, Italian, Spanish and Portuguese. Computer adaptivity is not established by the cited evidence and should not be assumed from remote delivery.
How do the two examination sections differ?
Clinical case questions unfold sequentially as additional information is introduced. They can require a single best answer, all correct responses or an ordered sequence; answered case questions cannot be revisited. The general clinical practice section uses standalone single-best-answer questions, and candidates can return to answered or unanswered questions within that section. The 20 questions here are independent four-option learning drills; they do not reproduce sequential case delivery or predict a passing result.
Does this guide cover EBIR-IO or another specialist certification?
The chosen pathway is general EBIR. CIRSE separately identifies specialist certifications including EBIR-IO and EBIR-ES. Its interventional-oncology curriculum is supplementary and supports specialist oncology certification for EBIR holders; it does not replace the general EBIR syllabus. Oncology remains one of the six domains within general EBIR.
How should European examination scope and international clinical guidance be used together?
The European curriculum defines the knowledge scope. Clinical references from CIRSE, IAEA, EAU, EANM and other professional societies support the mechanisms and decisions taught here. A recommendation's originating jurisdiction should remain clear: for example, the TIPS reference is a North American consensus and the sarcoma reference is UK guidance. Device authorisation and legal practice requirements remain jurisdiction-specific.
European Curriculum and Syllabus for Interventional Radiology — Third Edition · North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension · British Sarcoma Group — UK Guidelines for the Management of Bone Sarcomas, 2024
Independently authored preparation for CIRSE's European Board of Interventional Radiology examination, a voluntary supplemental assessment of physician-level clinical and technical IR knowledge. EBIR does not replace national specialist training or licensing. Clinical recommendations are supported by the cited clinical references, while the CIRSE syllabus establishes examination scope.
Outline used: European Curriculum and Syllabus for Interventional Radiology, Third Edition, February 2023; CIRSE states that this edition applies to EBIR examinations from March 2024 onward. Verified against the current issuer pages on 2026-10-10. The workbook name maps directly to EBIR; its Medical Licensing category is an administrative classification, whereas EBIR is a voluntary supplemental examination.
60 key concepts: understand, apply and avoid the traps
Work through the questions by exam domain. Explain the answer in your own words, try the example, then check the common pitfall.
Fundamental topics in interventional radiologynot stated
1.What makes consent an informed clinical decision?
Valid consent connects the proposed procedure to the patient's goals, expected benefit, important risks and reasonable alternatives. The discussion should include the option of declining intervention when relevant and allow questions before treatment. A signature documents the process but cannot substitute for understanding or voluntary agreement. The decisive cue is whether the patient can explain the proposed choice and its consequences, rather than merely repeat the procedure's name.
Apply it
A patient referred for embolisation believes it guarantees symptom resolution. Before scheduling treatment, explain the expected benefits, possibility of persistent symptoms, complications and alternatives, then ask the patient to describe the decision in their own words.
Common pitfall: Treating a signed form as proof of informed consent overlooks misunderstanding, coercion and material alternatives that could change the patient's choice.
2.How does patient selection differ from technical feasibility?
An intervention is appropriate when its expected clinical benefit justifies its burdens and risks for the individual patient. Accessible anatomy alone does not establish benefit. Review symptoms, disease trajectory, comorbidities, imaging, laboratory findings and available alternatives before choosing treatment. A discrepancy between the referral diagnosis and the patient's actual problem is a reason to reassess the indication. The interventional radiologist retains responsibility for determining appropriateness, even when another clinician requested the procedure.
Apply it
An arterial stenosis is easy to cross, but the patient's walking limitation is dominated by severe hip pain. Clarify the symptom mechanism and physiological significance before offering revascularisation as a solution to impaired mobility.
Common pitfall: Equating an impressive imaging abnormality with the cause of symptoms can produce technically successful treatment without meaningful improvement in the patient's condition.
3.How should bleeding and thrombosis risks shape antithrombotic planning?
Periprocedural antithrombotic decisions balance the procedure's bleeding risk against the consequences of interrupting treatment. Consider the drug, its indication, renal function, urgency and the anatomical consequences of bleeding. Deep organ biopsy differs from superficial sampling or routine catheter exchange. A recent high-risk thrombotic indication requires coordinated planning rather than automatic medication cessation. The useful decision is whether to proceed, modify the procedure or defer it after weighing both competing hazards.
Apply it
An elective deep organ biopsy is requested soon after coronary stenting. Review whether the result is urgently needed and discuss antiplatelet interruption with the treating specialist before setting a biopsy date or prescribing a medication hold.
Common pitfall: Applying one medication-hold rule to every procedure ignores differences in bleeding consequences and may expose a patient to preventable thrombosis.
4.Which renal findings and contrast routes change preventive planning?
Distinguish stable chronic renal impairment from known or suspected acute kidney injury, in which a creatinine-based eGFR may not reflect current function. ESUR identifies increased risk at eGFR below 45 mL/min/1.73 m² for intra-arterial first-pass renal exposure, and below 30 for intravenous or intra-arterial second-pass exposure. First-pass injections reach the renal arteries relatively undiluted, as with renal or suprarenal aortic injections; second-pass injections reach them after circulatory dilution. Risk identification supports alternatives where suitable, individualised intravenous preventive hydration, low- or iso-osmolar contrast, the lowest diagnostic dose and renal follow-up. It does not mandate automatic cancellation.
Apply it
A stable outpatient has an eGFR of 38 mL/min/1.73 m² and is scheduled for suprarenal aortography. This first-pass exposure crosses the below-45 risk threshold, so plan preventive measures and reassess contrast requirements. The same eGFR before intravenous CT does not cross the below-30 threshold, although acute injury or other clinical risks would change the assessment.
Common pitfall: Applying one eGFR cutoff to every injection route misses first-pass risk. A previously reassuring eGFR also does not exclude evolving acute injury, and hydration must be adjusted when heart failure makes fluid loading hazardous.
ESUR guidelines on Contrast Media - B. Renal adverse reactions
5.Why can normal oxygen saturation conceal inadequate ventilation?
Pulse oximetry measures oxygenation rather than ventilation. Supplemental oxygen may preserve saturation while sedation reduces respiratory rate or causes airway obstruction, allowing carbon dioxide to accumulate. Assess breathing clinically and monitor exhaled carbon dioxide during moderate or deep sedation whenever achievable. A deteriorating capnographic waveform or reduced respiratory effort warrants immediate assessment even before desaturation. Monitoring must be assigned to an appropriately trained person who can recognise deterioration and initiate rescue.
Apply it
During drainage under sedation, saturation remains normal on oxygen while breathing becomes shallow and the capnographic trace changes. Pause stimulation and medication administration, assess airway patency and support ventilation rather than waiting for saturation to fall.
Common pitfall: Increasing oxygen alone may improve the displayed saturation while leaving airway obstruction or respiratory depression untreated; oxygenation and ventilation require separate assessment.
American Society of Anesthesiologists — Standards for Basic Anesthetic Monitoring · CIRSE Clinical Practice Manual
6.How should procedural pain and anaesthetic depth be planned?
Anaesthetic planning depends on expected pain, procedure duration, required immobility, anxiety and the patient's physiological reserve. Local anaesthesia, systemic analgesia, sedation and general anaesthesia address different needs and may be combined. Sedation should not be used simply to suppress movement caused by inadequately treated pain. Anticipating a need for deep sedation or general anaesthesia changes staffing and airway planning. A deteriorating response to incremental medication is a cue to reassess the whole strategy.
Apply it
A patient repeatedly moves during a painful intervention despite increasing sedation. Reassess local anaesthesia and analgesia, procedural demands and airway risk, and obtain anaesthetic support when the required depth exceeds the team's planned capability.
Common pitfall: Escalating sedatives to overcome untreated pain can produce respiratory compromise without providing adequate analgesia or a reliably motionless procedural field.
7.How do collimation and stored fluoroscopy reduce radiation exposure?
Collimation limits the irradiated field and reduces scatter, while last-image hold allows inspection without additional irradiation. Select fluoroscopic pulse rates and acquisition modes that answer the current task; high-detail acquisition is unnecessary for every step. Geometric magnification and demanding exposure settings can increase dose. The practical discriminator is whether a new exposure supplies information needed for safe action. If the task is simply reviewing device position already shown, a stored image may suffice.
Apply it
After confirming a catheter's position, the team pauses to discuss the next step. Release fluoroscopy and use the stored image. Before resuming, collimate to the anatomy needed for the next manoeuvre and reassess imaging settings.
Common pitfall: Keeping fluoroscopy active during discussion adds exposure without improving decisions; enlarging the displayed image and selecting a magnification acquisition mode are not equivalent actions.
8.Where should shielding intercept occupational scatter?
The irradiated patient is a major source of scatter reaching staff during fluoroscopically guided procedures. Protective barriers work best when they interrupt the path from that scatter source to the operator. Position ceiling-suspended shielding close to the patient and between the exposed region and the operator's head and torso, with table-side protection where appropriate. Recheck barrier placement after changes in projection or working position. Distance and reduced patient exposure complement shielding.
Apply it
An operator changes sides to obtain a new catheter angle but leaves the ceiling shield behind. Reposition the barrier between the patient and the operator before continuing, while preserving access and avoiding interference with sterile equipment.
Common pitfall: A shield located nearby but outside the scatter path offers less protection than its presence suggests; protective clothing does not remove the need for positioned barriers.
IAEA SSG-46 — Occupational Radiation Protection in Image-Guided Interventional Procedures
9.Which imaging information is necessary for procedural planning?
Planning images must be sufficiently recent and detailed to establish the target, surrounding structures, access route and likely procedural hazards. The best guidance modality depends on target visibility, motion, route geometry and the information required during treatment. A prior diagnostic report cannot replace direct image review. When anatomy or disease has changed, additional imaging may alter positioning, equipment or even the indication. Choose images that resolve the decision rather than merely repeating an examination.
Apply it
A collection was identified on imaging several weeks earlier, but the patient has since undergone surgery. Review current anatomy before drainage because the target, bowel position and safe access corridor may have changed substantially.
Common pitfall: Planning solely from an old report assumes unchanged anatomy and overlooks details such as intervening bowel, new vessels or disappearance of the original target.
10.When should a procedural safety check stop progression?
A safety check is an active team verification of patient identity, intended procedure, anatomical site, relevant risks and readiness to manage complications. It is effective only if a discrepancy changes behaviour. Resolve inconsistent consent, missing essential information or unavailable critical equipment before proceeding. The check also creates a shared plan for medications, monitoring and aftercare. A team member's concern is clinically useful information and should be explored regardless of seniority or apparent scheduling pressure.
Apply it
The referral requests left-sided drainage, but the displayed images and consent describe a right-sided target. Stop progression, review the source images with the team and patient where possible, and reconcile the intended procedure before puncture.
Common pitfall: Reading a checklist aloud without resolving discrepancies converts a safety intervention into documentation and preserves the very error the check should prevent.
11.How does specimen handling determine diagnostic value?
A technically successful sample can become diagnostically useless if the wrong container, preservative, volume or transport process is chosen. Establish the intended analyses before sampling and allocate material accordingly. Microbiology requires appropriate sterile handling, while histology and specialised molecular investigations may have different requirements. Accurate labelling, clinical context and traceability link the specimen to the clinical question. When limited tissue must answer several questions, coordinate priorities with the receiving laboratory before the procedure.
Apply it
A lesion could represent malignancy or infection. Before biopsy, agree how cores will be divided for pathology and microbiology, prepare the required containers and document the differential diagnosis so that both investigations remain possible.
Common pitfall: Putting every specimen into one preservative may destroy the opportunity for culture or specialised testing, even when the needle sampled the correct lesion.
European Curriculum and Syllabus for Interventional Radiology — Third Edition
12.Why must technical success be followed by clinical assessment?
Technical success describes achievement of a procedural objective, such as placing a drain or excluding an aneurysm. Clinical success concerns improvement in the condition that justified treatment. These outcomes can diverge because of incomplete disease treatment, complications or an incorrect initial attribution of symptoms. Follow-up should therefore assess symptoms, physiological or laboratory change, relevant imaging and adverse events. An apparently satisfactory completion image does not establish that the patient's problem has resolved.
Apply it
A drain is correctly positioned, but fever and organ dysfunction persist. Reassess residual collections, catheter function, antimicrobial adequacy and alternative sources instead of concluding that the successful insertion has completed the patient's treatment.
Common pitfall: Using device deployment as the sole outcome overlooks persistent illness and delays recognition of treatment failure, complications or an additional diagnosis requiring action.
Vascular diagnosis and interventionnot stated
13.What does a noncompressible ankle–brachial index mean?
An ankle–brachial index above 1.40 indicates noncompressible ankle arteries rather than reliably normal limb perfusion. Arterial calcification can prevent cuff compression and produce an artificially elevated ankle pressure, particularly in diabetes or chronic kidney disease. Toe pressure and toe–brachial index with waveforms provide complementary physiological assessment. The discriminating clue is a high index that conflicts with symptoms, wounds or abnormal waveforms. Resolve that conflict before dismissing arterial insufficiency.
Apply it
A patient with diabetes has a toe ulcer and an ankle–brachial index of 1.52. Obtain toe pressure or toe–brachial index with waveforms to assess perfusion rather than classifying the ulcer as adequately perfused from the ankle measurement.
Common pitfall: Interpreting a very high ankle pressure as excellent circulation reverses its meaning when calcified arteries resist compression and make the measurement unreliable.
2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set
14.When can exercise testing clarify a normal resting vascular study?
A resting ankle–brachial index can be normal or borderline despite exertional arterial symptoms. Exercise increases flow demand and may reveal a pressure abnormality that is absent at rest. In a patient with compatible nonjoint-related exertional leg symptoms and a resting index above 0.90 through 1.40, exercise ankle–brachial testing helps assess peripheral arterial disease. The key distinction is demand-related symptoms; a normal resting measurement does not automatically settle their cause.
Apply it
A patient develops reproducible calf discomfort while walking, relieved by rest, but has a resting index of 1.04. Exercise ankle–brachial testing can investigate the mismatch before an anatomical lesion is sought for intervention.
Common pitfall: Moving directly from typical symptoms to angioplasty bypasses physiological confirmation, while dismissing disease solely because the resting index is normal can miss exertional ischaemia.
2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set
15.Which neurological findings make acute limb ischaemia immediately threatening?
Acute limb ischaemia classification depends on viability, especially sensory and motor function, rather than pain intensity alone. Limited toe sensory change without weakness is compatible with a marginally threatened limb. Sensory loss extending beyond the toes with new motor weakness indicates an immediately threatened limb requiring rapid reperfusion planning. Assessment should include arterial and venous Doppler signals and repeated neurological examination. An imaging strategy must not introduce avoidable delay when salvage depends on immediate treatment.
Apply it
A patient with sudden foot pain develops reduced ankle movement and sensory loss across the forefoot. Treat this as an immediately threatened limb and activate urgent revascularisation assessment rather than following a routine outpatient imaging sequence.
Common pitfall: Labelling every pulseless limb identically ignores the urgency conveyed by motor weakness and can delay salvage in a limb with deteriorating viability.
2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set · CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
16.Why does irreversible limb ischaemia change the treatment goal?
Profound anaesthesia, paralysis or rigor and absent arterial and venous Doppler signals suggest irreversible acute ischaemia. This differs from a threatened but salvageable limb. Reperfusing extensively nonviable muscle may release potassium, acids and other metabolites into the circulation without restoring useful function. The immediate decision becomes assessment for primary amputation and systemic stabilisation rather than routine reperfusion. Classification requires the combined examination; symptom duration or absent arterial pulses alone cannot establish irreversibility.
Apply it
A cold limb has fixed mottling, profound sensory loss, paralysis and no venous Doppler signal. Obtain urgent vascular assessment of nonviability and systemic risk instead of assuming that catheter thrombolysis remains the appropriate salvage strategy.
Common pitfall: Using elapsed time alone to declare a limb dead overlooks collateral circulation, while attempting reperfusion despite convincing nonviability can create serious systemic harm.
2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set · CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
17.How does chronic limb-threatening ischaemia require coordinated care?
Chronic limb-threatening ischaemia combines chronic ischaemic rest pain, tissue loss or gangrene with objectively demonstrated arterial disease. Limb outcome depends on wound extent, perfusion and infection, not stenosis severity alone. Revascularisation planning should therefore connect arterial anatomy with wound care, infection control, pressure relief and the patient's functional goals. A technically patent artery may be insufficient if infected or mechanically stressed tissue remains untreated. Assessment should address both limb preservation and cardiovascular risk.
Apply it
A patient has a nonhealing forefoot ulcer, poor toe perfusion and local infection. Coordinate revascularisation with infection management, wound treatment and offloading, using the wound and functional objective to guide the overall plan.
Common pitfall: Treating the angiogram as the whole disease overlooks infection and wound mechanics, which can prevent healing despite improved arterial flow after intervention.
2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set
18.Why do attachment-site and graft-defect endoleaks require prompt action?
Type I endoleak reflects failure of the seal at a graft attachment site, whereas type III results from component separation or a graft defect. Both can expose the aneurysm sac directly to systemic arterial pressure and carry rupture risk. Their mechanisms differ from retrograde branch filling in type II endoleak. Identify the entry site and graft integrity rather than classifying every enhancing sac similarly. Prompt correction generally aims to restore a durable seal or graft continuity.
Apply it
Surveillance CT shows contrast entering an aneurysm sac beside the proximal graft attachment. Assess this as proximal seal failure and arrange prompt specialist treatment planning rather than applying a stable type II endoleak surveillance approach.
Common pitfall: Waiting for substantial sac enlargement before addressing a clear attachment-site leak overlooks the direct pressurisation mechanism and its associated risk of rupture.
CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair
19.When is surveillance reasonable for a type II endoleak?
Type II endoleak arises from retrograde flow through aortic branches, commonly lumbar arteries or the inferior mesenteric artery. Management depends importantly on aneurysm sac behaviour. An isolated type II endoleak with a stable sac can usually be observed with imaging surveillance. Sac enlargement changes the assessment and should trigger investigation for persistent branch perfusion or an occult higher-pressure leak. The decision rests on mechanism and serial change, rather than enhancement alone.
Apply it
A small lumbar-artery endoleak is visible after EVAR, but serial imaging shows no sac enlargement. Continue structured surveillance while documenting sac dimensions, graft integrity and any change in the pattern of enhancement.
Common pitfall: Assuming every enlarging sac with visible branch flow has only a type II leak can miss an additional attachment-site or graft-integrity failure.
CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair
20.Why must pseudoaneurysm embolisation account for both inflow and outflow?
A pseudoaneurysm with patent inflow and outflow may remain perfused through collateral backfilling after proximal occlusion alone. Isolation, often called sandwich embolisation, excludes relevant outflow and inflow pathways to prevent continued sac pressurisation. The sequence commonly secures the distal route before proximal access is lost. Before sacrificing the parent artery, assess collateral supply and organ tolerance. The decisive anatomical question is whether another route can still deliver blood to the injured segment.
Apply it
A gastroduodenal-region pseudoaneurysm receives flow through an arterial arcade. Plan exclusion of the distal and proximal connections, with completion assessment for collateral filling, rather than placing a single proximal coil and assuming the sac is isolated.
Common pitfall: A reassuring proximal angiogram can conceal retrograde perfusion through another arterial territory; exclusion requires assessment of the entire relevant inflow–outflow circuit.
21.When can a covered stent preserve flow during aneurysm exclusion?
A covered stent can exclude an aneurysm or pseudoaneurysm while maintaining parent-vessel flow. Suitability depends on deliverability, vessel geometry, adequate proximal and distal sealing zones and the consequences of covering branches. Tortuous vessels or an inadequate landing zone may prevent reliable exclusion. This strategy is particularly attractive when parent-artery sacrifice would threaten organ perfusion. The decision compares a durable seal and preserved flow against branch loss, thrombosis risk and the practical demands of follow-up.
Apply it
A visceral pseudoaneurysm lies in a relatively straight artery whose distal territory has limited collateral supply. Review sealing zones and branch origins to determine whether covered-stent exclusion can preserve perfusion more safely than parent-vessel occlusion.
Common pitfall: Choosing a flow-preserving device without checking its sealing zones or covered branches can exchange aneurysm perfusion for persistent leakage or clinically important ischaemia.
22.Which angiographic finding makes bronchial embolisation hazardous to the spinal cord?
Bronchial and intercostobronchial arteries may communicate with vessels supplying the spinal cord. Embolic material entering these branches can cause spinal cord infarction. Review selective angiography carefully for critical branches before embolisation and reassess the safety of the catheter position and planned embolic delivery. A branch leading to the spinal circulation is a major warning, not an incidental variant. Safe treatment requires a strategy that prevents embolic access to that circulation.
Apply it
Selective angiography for haemoptysis shows a branch coursing toward the spinal canal. Stop the planned particle injection and reassess whether a demonstrably safe selective position or alternative treatment strategy is available.
Common pitfall: Assuming a vessel is safe because it supplies abnormal lung ignores shared origins and collateral connections that can carry embolic material into critical neural circulation.
CIRSE Standards of Practice on Bronchial Artery Embolisation
23.How should recurrent haemoptysis after embolisation be investigated?
Recurrent haemoptysis may reflect recanalisation, untreated abnormal arteries, recruitment of nonbronchial systemic collaterals or progression of the underlying disease. Repeat assessment should reconsider the bleeding territory and arterial supply rather than automatically repeating the previous catheterisation. Cross-sectional angiographic imaging can help map new or missed pathways when the patient's airway and stability permit. Embolisation controls bleeding but does not eliminate causes such as chronic infection or malignancy, which require parallel disease-directed treatment.
Apply it
Haemoptysis returns months after successful bronchial embolisation in a patient with chronic inflammatory lung disease. Reassess bronchial and nonbronchial systemic supply and the underlying disease before choosing the vessels for repeat treatment.
Common pitfall: Treating recurrence as proof of failure in the same artery may miss newly recruited collateral vessels or a different bleeding source requiring a changed approach.
CIRSE Standards of Practice on Bronchial Artery Embolisation
24.Why can TIPS precipitate cardiac decompensation?
TIPS diverts portal blood into the systemic venous circulation, increasing venous return and cardiac workload. Patients with severe heart failure, severe untreated valvular disease or significant pulmonary hypertension may not tolerate this haemodynamic change. The North American consensus recommends cardiopulmonary evaluation before elective TIPS and identifies important cardiac contraindications. Refractory ascites establishes a possible indication, but does not override a contraindication. The discriminating issue is the heart's ability to accommodate the increased preload.
Apply it
A patient with refractory ascites also has symptomatic severe heart failure. Evaluate the cardiac disease and alternative ascites management rather than proceeding directly to elective TIPS on the strength of the portal-hypertension indication.
Common pitfall: Viewing TIPS solely as a liver procedure overlooks its systemic haemodynamic effects and can expose a vulnerable patient to acute cardiac deterioration.
25.Which factors make post-TIPS encephalopathy more likely?
TIPS allows portal blood to bypass hepatic processing, increasing exposure to substances involved in hepatic encephalopathy. Prior overt encephalopathy, advanced age, impaired liver function, renal dysfunction, hyponatraemia and sarcopenia inform risk assessment. These factors require counselling and careful selection rather than a universal numerical exclusion rule. Refractory overt encephalopathy is a stronger boundary: the North American recommendations identify it as an absolute contraindication to elective TIPS. Distinguish a previous controlled episode from ongoing refractory disease.
Apply it
A patient being assessed for elective TIPS has recurrent overt encephalopathy despite treatment and substantial sarcopenia. Review the refractory neurological disease and overall suitability before assuming that portal decompression will improve the patient's net outcome.
Common pitfall: Treating any historical encephalopathy episode as identical to refractory overt disease loses an important distinction in contraindication assessment and individual risk counselling.
26.How should recurrent VTE during anticoagulation affect IVC filter decisions?
An IVC filter intercepts some emboli but does not treat venous thrombosis. SIR recommends against routine filters during therapeutic anticoagulation and generally advises against placement for recurrent VTE, with few exceptions. First confirm a genuinely new event by comparison with prior imaging, then assess adherence, prescribed and received dosing, interactions, absorption and therapeutic exposure using measures appropriate to the anticoagulant. Correct remediable causes and optimise anticoagulation. Exceptional filter consideration concerns confirmed recurrence with no modifiable explanation when another embolus poses substantial cardiopulmonary risk. Acute VTE with a contraindication to anticoagulation is a separate indication requiring individual risk assessment.
Apply it
A new PE is reported during anticoagulation. Compare current and previous imaging and establish whether treatment was actually therapeutic, including missed doses or interacting drugs. Optimise treatment first. If recurrence persists despite verified appropriate therapy, no correctable cause exists and cardiopulmonary reserve is severely limited, discuss exceptional filter use after weighing device harms and alternatives.
Common pitfall: Calling persistent residual thrombus or inadequate drug exposure 'anticoagulation failure' can lead to unnecessary filter placement. Recurrence alone is not a routine filter indication.
27.Why must retrievable IVC filters have an active follow-up plan?
A retrievable filter may outlast the temporary condition that justified placement. Continued implantation can expose the patient to device-related complications after the initial benefit has diminished. SIR recommends a follow-up programme to detect complications and increase retrieval, with removal when pulmonary embolic risk has resolved unless removal risk outweighs benefit. Assign responsibility and a reassessment trigger at placement. The relevant decision is whether the indication persists, not whether the device remains technically retrievable.
Apply it
A filter was placed during a temporary bleeding contraindication. Once bleeding is controlled and anticoagulation becomes feasible, arrange reassessment of embolic risk and retrieval suitability through the service responsible for filter follow-up.
Common pitfall: Writing 'retrievable filter' in the procedure report does not ensure removal; an unassigned follow-up task can leave a temporary device implanted indefinitely.
Society of Interventional Radiology Publishes IVC Filter Guidelines
28.Which clinical changes suggest haemodialysis access dysfunction?
Dialysis access dysfunction is recognised through clinical and treatment-performance changes, including altered thrill, high circuit pressures, low flow, prolonged postdialysis bleeding, arm oedema or reduced dialysis adequacy. These findings help distinguish a clinically important access problem from an isolated anatomical narrowing. Evaluation should consider the whole circuit, including inflow, anastomosis, outflow and central veins. A stenosis can contribute to thrombosis, so a thrombosed access requires investigation of the lesion that caused failure.
Apply it
A fistula develops prolonged bleeding after needle removal and increasing venous pressures during dialysis. Examine the access and assess its venous outflow and central drainage rather than attributing the change solely to needle placement.
Common pitfall: Restoring flow through a thrombosed access without identifying the associated circuit lesion can leave the mechanism of failure in place and invite early recurrence.
European Curriculum and Syllabus for Interventional Radiology — Third Edition
29.How should lower urinary tract symptoms be evaluated before prostate artery embolisation?
Prostate artery embolisation assessment begins by characterising lower urinary tract symptoms and determining whether benign prostatic disease explains them. Voiding and storage symptoms should be distinguished, baseline symptom burden documented and imaging reviewed for benign and malignant disease. The International Prostate Symptom Score measures symptoms but does not establish their cause. Discuss medical, endoscopic, surgical and embolisation options in that context. The important cue is concordance between the symptoms, prostate assessment and proposed treatment mechanism.
Apply it
A man requests embolisation because his symptom score is high, but storage symptoms dominate and the cause remains uncertain. Complete the clinical and urological assessment before assuming that treatment directed at prostatic blood supply addresses the problem.
Common pitfall: Using symptom severity as a diagnosis overlooks other explanations for lower urinary tract symptoms and can lead to treatment of the wrong mechanism.
European Curriculum and Syllabus for Interventional Radiology — Third Edition
30.Which factors should determine a central venous access device?
Central venous device selection should match treatment purpose, expected duration, frequency of access, flow requirements, venous anatomy and the patient's circumstances. A dialysis catheter, implanted port and peripherally inserted central catheter serve different needs. Review previous devices and thrombosis before selecting a route, and consider future vascular access requirements. The practical discriminator is the intended therapy: a convenient insertion route does not make a device suitable for every infusion or extracorporeal treatment.
Apply it
A patient needs intermittent long-term cancer treatment and has a history of central venous thrombosis. Review venous patency, treatment requirements and maintenance preferences before choosing a device and access side.
Common pitfall: Selecting a device solely because insertion is familiar can overlook inadequate flow characteristics, maintenance burdens, unavailable veins or consequences for future access.
European Curriculum and Syllabus for Interventional Radiology — Third Edition
Non-vascular interventions in the chest, gastrointestinal tract and hepatobiliary systemsnot stated
31.How should a lung biopsy trajectory minimise pneumothorax risk?
Lung biopsy planning balances diagnostic access with injury to aerated lung and pleura. Emphysema along the needle path, fissure traversal and repeated pleural passages increase pneumothorax risk. Review the complete trajectory rather than selecting the shortest skin-to-lesion distance alone. A route through less vulnerable lung with fewer pleural crossings may be preferable even if slightly longer. Patient position, target motion and the ability to obtain sufficient material also influence the final approach.
Apply it
Two routes reach a peripheral nodule: one crosses a fissure and emphysematous lung, while the other avoids both. Prefer the safer anatomical corridor when it still permits reliable target sampling and acceptable needle control.
Common pitfall: Choosing the shortest route without examining the tissue it crosses can increase complications; path length is only one component of a safe biopsy plan.
32.When does post-biopsy pneumothorax require drainage?
Management of post-biopsy pneumothorax depends on symptoms, oxygenation, physiological reserve, size and progression. A small stable pneumothorax in an asymptomatic patient may be observed with appropriate monitoring. Aspiration can be considered for a suitable symptomatic or larger pneumothorax, while persistent air leak, recurrence after aspiration, enlargement or respiratory compromise favours catheter drainage. Imaging size alone does not capture the effect on a patient with limited pulmonary reserve. Continue reassessment and explain delayed symptoms because an initially reassuring examination does not exclude later pneumothorax.
Apply it
A patient develops increasing dyspnoea and hypoxaemia with a pneumothorax that reaccumulates after aspiration. Arrange pleural catheter drainage and supportive care rather than continuing observation or repeated aspiration despite ongoing deterioration.
Common pitfall: Applying a single radiographic-size rule ignores clinical deterioration, persistence and baseline lung disease, which can make an apparently modest pneumothorax poorly tolerated.
33.How should haemoptysis after lung biopsy be assessed?
Assess post-biopsy haemoptysis by its rate, airway effects, oxygenation, haemodynamic consequences and the patient's reserve, rather than estimated volume alone. Mild bleeding often settles with conservative management and biopsy-side-down positioning, which helps protect the unaffected lung. Escalating bleeding or impaired gas exchange requires airway support and urgent specialist management. Maintaining ventilation and preventing blood contamination of the other lung take precedence over completing the diagnostic sampling plan.
Apply it
Following right-lung biopsy, a patient coughs blood but remains stable. Stop sampling, monitor closely and position the right side down. If oxygenation or airway clearance deteriorates, escalate promptly for airway management and haemorrhage control.
Common pitfall: Reassurance based only on a seemingly small measured volume can miss dangerous rapid bleeding or airway obstruction in a patient with limited respiratory reserve.
34.Why does an infected collection require source control?
An infected collection can maintain sepsis despite antimicrobial treatment because the infected material remains in place. Source control removes or drains that reservoir while antibiotics and resuscitation address systemic infection. Imaging establishes the collection's location, complexity and access options. When percutaneous drainage is appropriate, choose a route that avoids unnecessary injury and permits useful catheter positioning. Clinical improvement, not just catheter insertion, determines whether the chosen source-control strategy has worked.
Apply it
A postoperative patient remains septic with a drainable abdominal abscess despite antibiotics. Coordinate prompt image-guided drainage, obtain appropriate samples and continue systemic treatment, then reassess organ function and the residual collection.
Common pitfall: Waiting for antibiotics alone to sterilise a persistent septic collection can delay source control; conversely, drainage does not remove the need for antimicrobial and supportive treatment.
CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
35.How should persistent sepsis after drainage be investigated?
Persistent sepsis after drainage requires reassessment of both source control and the broader diagnosis. A catheter may be obstructed, displaced or positioned in only one component of a multiloculated collection. Another collection or an ongoing leak may sustain infection. Review clinical trends, catheter output and repeat imaging as indicated rather than judging success from the initial insertion. The key distinction is between a catheter that remains present and a source that has actually been controlled.
Apply it
Drain output falls abruptly while fever continues and imaging shows a residual multiloculated abscess. Evaluate catheter patency and position and whether additional compartments need drainage before interpreting low output as evidence of resolution.
Common pitfall: Low drain output may indicate blockage rather than recovery; removing the catheter without correlating output with symptoms and imaging can leave infection untreated.
CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026 · CIRSE Clinical Practice Manual
36.When is percutaneous biliary drainage an emergency?
Acute cholangitis with obstruction can progress rapidly to sepsis and organ failure. Management combines resuscitation, antibiotics and timely biliary decompression. When endoscopic drainage is contraindicated, infeasible or unsuccessful, percutaneous transhepatic drainage provides an alternative route to source control. In an unstable infected patient, effective drainage is the immediate objective; complex definitive treatment can often be staged. Jaundice alone and septic obstructed bile ducts therefore represent different levels of urgency.
Apply it
A patient with obstructed bile ducts has hypotension and infection, and endoscopic access has failed. Arrange urgent percutaneous decompression alongside antibiotics and resuscitation rather than waiting for an elective definitive stenting session.
Common pitfall: Focusing first on durable stent placement or stone clearance can prolong a procedure when rapid decompression and stabilisation are the immediate clinical objectives.
CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
37.How does drainage of a biloma differ from treatment of cholangitis?
A biloma is an extrabiliary bile collection, whereas obstructive cholangitis involves infected bile within an obstructed ductal system. Draining the collection can provide initial control of a postoperative or traumatic leak, with biliary diversion considered according to the ongoing leak and clinical course. Percutaneous duct access may be harder when ducts are not dilated. Identify whether the immediate problem is infected collected bile, obstructed ducts or both before choosing the drainage target.
Apply it
A postoperative patient has a symptomatic infected biloma without marked duct dilatation. Drain the collection and assess the leak, recognising that transhepatic biliary diversion may be staged rather than being the only immediate source-control option.
Common pitfall: Assuming every bile-related collection requires immediate transhepatic duct access overlooks the value of direct collection drainage and the difficulty of accessing nondilated ducts.
CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
38.What trade-off follows covering an oesophageal stent?
A covered oesophageal stent creates a barrier that resists tumour ingrowth through the mesh and can seal a malignant fistula or leak. Reduced tissue incorporation also increases the tendency to migrate compared with an uncovered device. Selection therefore depends on whether the main objective is luminal patency, fistula sealing or another anatomical requirement. Covering does not prevent tumour overgrowth at the ends, food obstruction or every cause of recurrent dysphagia.
Apply it
A patient with malignant oesophageal obstruction and an associated fistula needs palliation. A covered stent can address both obstruction and sealing, but planning and follow-up must account for migration and recurrent symptoms.
Common pitfall: Assuming the covering prevents every form of tumour-related obstruction ignores overgrowth at the stent ends and trades away awareness of the increased migration risk.
CIRSE Standards of Practice on Oesophageal and Gastroduodenal Stenting
39.Which mechanisms explain recurrent dysphagia after oesophageal stenting?
Recurrent dysphagia after stenting may result from migration, food bolus obstruction, tumour ingrowth, tumour overgrowth or tissue hyperplasia. The timing, stent position and imaging or endoscopic appearance help distinguish these mechanisms. An uncovered stent is more vulnerable to ingrowth, while a covered stent can still migrate or develop end overgrowth. Treatment should address the demonstrated cause rather than automatically placing a second stent whenever swallowing becomes difficult again.
Apply it
Swallowing worsens after initial improvement with a covered stent. Assess its position and lumen to distinguish migration or food obstruction from tumour overgrowth before selecting clearance, repositioning or additional stenting.
Common pitfall: Attributing every recurrence to tumour progression can miss a removable food bolus or migrated device and lead to unnecessary additional hardware or treatment delay.
CIRSE Standards of Practice on Oesophageal and Gastroduodenal Stenting
40.When should acute cholecystitis be treated with drainage rather than early surgery?
Elevated surgical risk does not itself establish that a patient is unsuitable for surgery. WSES recommends early laparoscopic cholecystectomy for many high-risk patients with acute calculous cholecystitis because it treats the infected gallbladder and the underlying gallstone problem. Gallbladder drainage supports patients unsuitable for surgery, particularly when ongoing infection requires source control. Percutaneous cholecystostomy may bridge to later surgery if fitness improves, or support a nonsurgical strategy when operative unsuitability persists. A gallbladder drain does not automatically decompress an obstructed main biliary tree.
Apply it
A critically ill patient has acute cholecystitis and prohibitive immediate operative risk. Consider image-guided gallbladder drainage with antibiotics and supportive treatment, then reassess suitability for definitive surgery after stabilisation. A different patient with significant comorbidity but acceptable operative fitness may still benefit most from early laparoscopic cholecystectomy.
Common pitfall: Equating 'high risk' with 'unsuitable for surgery' can divert patients from preferred definitive treatment. Confusing gallbladder drainage with main-duct drainage can also leave the actual infected compartment undrained.
Intervention of the genito-urinary tract and renal transplantsnot stated
41.Why is an infected obstructed kidney a decompression emergency?
Urinary obstruction prevents drainage of an infected collecting system and can drive sepsis and renal injury. Immediate treatment combines antibiotics, cultures, resuscitation and urgent decompression using nephrostomy or a ureteric stent according to feasibility. Definitive stone treatment is generally delayed until infection has resolved. The decisive combination is infection plus obstruction, not stone size alone. Antibiotics cannot reliably compensate for a persistently obstructed infected system that requires source control.
Apply it
A patient has fever, hypotension and hydronephrosis above a ureteric stone. Arrange urgent drainage with antimicrobial and supportive treatment, leaving definitive stone fragmentation for a later stage after the infection has been controlled.
Common pitfall: Attempting definitive stone removal during uncontrolled sepsis increases procedural burden when the immediate goal is drainage; observation based on a small stone misses the emergency.
42.Which anatomy should guide nephrostomy calyceal access?
Nephrostomy planning identifies a suitable calyx and a tract avoiding bowel, pleura and major vessels. A posterolateral calyceal approach can pass through relatively hypovascular renal parenchyma. The optimal calyx also depends on the intended next step: access for antegrade ureteric work may require a different angle from drainage alone. Ultrasound and other planning images establish the actual anatomy. A familiar lower-pole route is not universally the safest or most useful choice.
Apply it
Antegrade stenting is planned through a tight ureteric stricture. Review whether an interpolar calyx offers a more favourable working angle while retaining a safe tract that avoids bowel, pleura and visible vasculature.
Common pitfall: Selecting the same calyx for every procedure ignores renal orientation, intervening structures and the mechanical demands of subsequent guidewire and catheter manipulation.
CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026
43.Why should infected collecting systems be manipulated at low pressure?
Pressurising an infected obstructed collecting system can promote bacteraemia and acute septic deterioration. Once purulent urine or known infection establishes the problem, prioritise secure drainage and avoid unnecessary contrast injection or guidewire manipulation. Detailed anatomical mapping and difficult internalisation can often wait until infection is controlled. The critical distinction is between the minimum manoeuvres needed to drain safely and additional diagnostic or therapeutic steps that increase pressure without immediate benefit.
Apply it
Purulent urine is aspirated during emergency nephrostomy. Establish drainage with minimal necessary manipulation rather than injecting contrast to fully display the ureter or repeatedly attempting to cross the obstruction during the septic episode.
Common pitfall: Treating an infected system like an elective pyelogram can trigger deterioration; a technically attractive full contrast study is not the priority when pus is encountered.
CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026
44.How should a ureteric stent be followed after placement?
A ureteric stent requires a documented plan for removal, exchange or continued surveillance because occlusion, encrustation, infection and migration can develop during implantation. Record the device, indication, insertion date and responsible service, and communicate the plan to the patient. Exchange timing depends on device characteristics and clinical circumstances. New fever, pain, reduced urine output or worsening renal function should trigger reassessment rather than being deferred until the planned exchange date.
Apply it
A patient receives a stent for persistent malignant obstruction. Before discharge, assign follow-up responsibility, document the intended exchange plan and explain which symptoms should prompt urgent review even if the next appointment is months away.
Common pitfall: Assuming internal drainage needs no ongoing management can create a forgotten stent; a scheduled exchange also does not exclude earlier obstruction or infection.
CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026
45.How does transplant anatomy change obstruction assessment and access?
A transplanted kidney has altered position, orientation and ureteric and vascular anastomoses, so native-kidney access assumptions may be unsafe. Review the operative anatomy, current ultrasound and potential intervening structures before puncture. Obstruction threatens the functioning graft without compensation from a normal contralateral kidney in many recipients, increasing the importance of timely decompression. Rising creatinine requires assessment for urinary, vascular and parenchymal causes rather than automatic attribution to rejection.
Apply it
A transplant recipient develops rising creatinine and collecting-system dilatation. Assess graft anatomy and the cause of impaired drainage promptly, planning access from the transplant's actual orientation rather than using a standard prone native-kidney approach.
Common pitfall: Assuming a transplanted kidney follows native retroperitoneal geometry risks an unsafe tract and can delay recognition of a reversible obstructive cause of graft dysfunction.
CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026 · European Curriculum and Syllabus for Interventional Radiology — Third Edition
46.Why can elevated bladder pressure mimic ureteric stent failure?
Stented ureters may have impaired effective peristalsis and depend on a sufficiently low-pressure bladder for drainage. Elevated intravesical pressure from lower urinary tract obstruction can therefore impair upper-tract drainage even when the ureteric stent remains patent. Evaluate bladder emptying and the entire drainage pathway before repeatedly exchanging the stent. The useful clue is upper-tract dilatation accompanied by retention or a high-pressure bladder, suggesting a downstream functional problem rather than device occlusion alone.
Apply it
Hydronephrosis persists despite a correctly positioned stent, and the patient has a distended bladder with substantial retention. Address bladder drainage and reassess the upper tract before assuming that another ureteric device is required.
Common pitfall: Focusing only on the ureteric stent can miss downstream obstruction; replacing a patent device does not correct the pressure opposing drainage into the bladder.
CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026
47.Which stone characteristics can noncontrast CT clarify?
Noncontrast CT can establish stone location, burden, density and surrounding anatomy when evaluating suspected urinary stones after initial assessment. These findings help select treatment and identify alternative causes of pain when no stone is present. A stone invisible on a plain radiograph may still be visible on CT, including uric acid stones. Imaging interpretation must remain linked to infection, renal function and obstruction because those clinical findings can determine urgency independently of stone dimensions.
Apply it
A patient has persistent flank pain and an inconclusive ultrasound with no stone visible on plain radiography. Noncontrast CT can clarify stone presence and location and assess other explanations, while fever or a solitary kidney increases urgency.
Common pitfall: Equating radiolucency on plain imaging with invisibility on CT can miss uric acid stones; identifying a stone also does not exclude clinically important infection.
Intervention of the musculoskeletal systemnot stated
48.Why must a suspected bone sarcoma biopsy follow the surgical plan?
A biopsy tract can contaminate tissues with tumour and may need excision during definitive surgery. Suspected bone sarcoma biopsy should therefore be planned with the specialist surgical team after appropriate cross-sectional imaging. The route should obtain representative tissue while minimising contamination of uninvolved compartments and preserving future reconstruction options. The shortest route is not automatically correct. A poorly planned biopsy can compromise limb-sparing treatment even when it produces an accurate histological diagnosis.
Apply it
A deep bone lesion has two accessible biopsy routes, but one crosses an uninvolved compartment outside the anticipated resection. Agree the tract with the sarcoma team and select an approach compatible with definitive surgery.
Common pitfall: Optimising only needle convenience can enlarge the eventual surgical field; diagnostic yield does not compensate for avoidable contamination of tissue needed for limb salvage.
British Sarcoma Group — UK Guidelines for the Management of Bone Sarcomas, 2024
49.How should bone tumour sampling preserve diagnostic options?
Bone tumour diagnosis may require histology, microbiology and molecular or cytogenetic investigation. Plan specimen allocation with the specialist pathology service before sampling, and provide the anatomical site, age and imaging differential. Cross-sectional imaging helps select a representative target, particularly in heterogeneous lesions. A limited sample from a low-grade or nonrepresentative region may not characterise the whole tumour. The correct diagnostic pathway combines planned tissue handling with radiological and specialist pathological interpretation.
Apply it
A heterogeneous bone lesion contains a suspicious dedifferentiated area. Coordinate image-guided targeting and specimen allocation with the sarcoma pathologist so that routine morphology and necessary molecular or microbiological studies can all be performed.
Common pitfall: Submitting all tissue without advance laboratory planning may prevent essential specialised tests; sampling an accessible but unrepresentative region can also underestimate tumour aggressiveness.
British Sarcoma Group — UK Guidelines for the Management of Bone Sarcomas, 2024
50.Why must a cryoablation ice ball extend beyond the tumour?
The visible ice-ball boundary is not the boundary of uniformly lethal freezing. Temperatures at its periphery may be insufficient for reliable cell death, so curative treatment requires the visible ice ball to extend beyond the tumour. CIRSE's bone-ablation guidance describes a 5–8 mm extension for curative cryoablation. Coverage must be assessed in multiple planes and balanced against protection of adjacent structures. Merely touching every tumour edge with visible ice does not establish an adequate ablative margin.
Apply it
During bone cryoablation, the visible ice ball reaches the tumour boundary on axial images but has no surrounding margin. Reassess multiplanar coverage and probe strategy before accepting this as complete curative treatment.
Common pitfall: Equating the visible ice edge with a lethal isotherm overestimates tumour destruction; extending ice blindly near nerves trades inadequate tumour coverage for unacceptable collateral injury.
CIRSE Standards of Practice on Thermal Ablation of Bone Tumours
51.How can neural structures be protected during bone ablation?
Neural protection combines careful probe placement, passive monitoring and active measures such as displacement or temperature modulation. CIRSE recommends nonionic 5% dextrose for hydrodissection during radiofrequency ablation, whereas saline or dextrose may be used during cryoablation. Thermosensors assess temperature near vulnerable neural structures; during heat ablation with spinal thermometry, cease energy delivery when the monitored temperature reaches 45°C. Electrophysiological monitoring can detect functional deterioration under general anaesthesia: stop energy delivery immediately if motor-evoked potentials deteriorate. General anaesthesia removes patient feedback and does not itself protect the nerve from thermal damage.
Apply it
A vertebral lesion lies near a nerve root. Plan protective displacement where feasible, choosing nonionic 5% dextrose for RFA hydrodissection or saline or dextrose for cryoablation. During heat ablation, stop if spinal thermometry near the neural structure reaches 45°C. Stop immediately for deteriorating motor-evoked potentials, then reassess temperature, probe position and protection before considering further treatment.
Common pitfall: Using saline for RFA hydrodissection overlooks the recommended nonionic fluid distinction. Continuing because the patient is comfortable under anaesthesia ignores absent sensory feedback; neither reassuring probe position nor a temperature below the stopping threshold overrides deteriorating motor-evoked potentials.
CIRSE Standards of Practice on Thermal Ablation of Bone Tumours · Client Challenge
52.When should ablation be combined with bone consolidation?
Ablation treats tumour tissue but does not reliably restore the mechanical strength of a lytic weight-bearing lesion. Cement augmentation or other stabilisation may be needed to reduce fracture risk and address mechanical pain. Evaluate cortical destruction, location, loading and existing fracture before selecting a combined approach. When cement follows thermal ablation, allow appropriate temperature normalisation for predictable cement behaviour. Tumour control, neural safety and structural stability are separate objectives requiring an integrated treatment plan.
Apply it
A painful lytic acetabular metastasis is suitable for ablation but substantially weakens a load-bearing region. Assess consolidation or fixation requirements alongside tumour treatment instead of assuming pain relief alone establishes mechanical safety.
Common pitfall: Successful tumour ablation can leave a structurally fragile bone; immediate cement injection without considering residual temperature can also make its setting behaviour less predictable.
CIRSE Standards of Practice on Thermal Ablation of Bone Tumours
Interventional oncologynot stated
53.How should oncological treatment intent determine the outcome measured?
Interventional oncology may pursue local eradication, disease control, palliation or support for another definitive treatment. The intended outcome should be agreed before treatment and matched to the patient's disease distribution, reserve and priorities. A palliative procedure may be valuable through symptom relief even without complete tumour destruction; a curative procedure requires a different assessment of local control. Technical delivery, symptom improvement and cancer response should therefore be recorded as distinct outcomes rather than treated as interchangeable.
Apply it
A patient with disseminated cancer undergoes treatment of one painful bone metastasis. Define pain relief and functional improvement as key objectives while continuing systemic disease management, rather than presenting local treatment as eradication of the cancer.
Common pitfall: Using a local imaging endpoint as proof of overall cancer benefit can exaggerate results and obscure whether the procedure achieved the patient's actual treatment goal.
CIRSE Standards of Practice on Thermal Ablation of Bone Tumours · CIRSE Clinical Practice Manual
54.Why can viable-tumour assessment outperform size alone after HCC treatment?
Locoregional treatment can produce necrosis and reduced perfusion before the overall lesion shrinks. For hepatocellular carcinoma, modified RECIST assesses the enhancing viable tumour component rather than total lesion diameter alone. A mass that remains similar in size can therefore show meaningful response if viable enhancement decreases. Interpretation requires suitable contrast phases and comparison with baseline imaging. This principle is tumour-specific: response criteria appropriate for HCC should not be transferred automatically to every hepatic metastasis.
Apply it
After radioembolisation, an HCC lesion remains similar in overall diameter but its arterial enhancing component has markedly decreased. Assess viable-tumour response with appropriate criteria rather than calling treatment ineffective solely because the mass has not shrunk.
Common pitfall: Applying total-size criteria indiscriminately can miss necrotic response in HCC; conversely, absent shrinkage does not excuse overlooking persistent or increasing viable enhancement.
55.How should modality, margins and organ protection guide visceral tumour ablation?
Visceral ablation planning considers tumour size, location, perfusion and the ability to cover the tumour plus a circumferential margin. Radiofrequency ablation heats tissue through electrical current; microwave ablation uses electromagnetic energy and is less susceptible to perfusion-related heat loss, although nearby flow can still affect treatment. Cryoablation permits visualisation of the ice ball, but its visible edge is not uniformly lethal. Plan overlapping treatment zones where required and inspect coverage in multiple planes. Protect bowel, ducts, collecting systems and other vulnerable structures through a safe trajectory, displacement or protective temperature control appropriate to the organ and modality.
Apply it
A small renal tumour lies beside bowel. Consider whether cryoablation's visible treatment boundary aids monitoring, but establish a protective separation before freezing and allow for the lethal zone lying inside the ice edge. For a liver lesion beside a large vessel, account for heat loss when choosing the modality and probe arrangement. If adequate margins and organ protection cannot both be achieved, revise the treatment approach.
Common pitfall: A probe centred in a tumour does not prove complete ablation. Neither a nominal device treatment diameter nor visible ice touching the tumour boundary establishes a circumferential lethal margin or protection of adjacent organs.
European Curriculum and Syllabus for Interventional Radiology — Third Edition · CIRSE Standards of Practice on Thermal Ablation of Bone Tumours
56.How is the lung-shunt fraction calculated before radioembolisation?
The lung-shunt fraction estimates the proportion of measured activity reaching the lungs rather than remaining in the hepatic distribution. Using appropriately processed counts, divide lung counts by the sum of lung and liver counts. A result expressed as a percentage requires multiplication by 100. This fraction contributes to lung-dose assessment but does not alone determine treatment eligibility. Imaging method, corrections, intended activity, product and dosimetric approach influence interpretation and must remain separate from the arithmetic.
Apply it
A simplified study provides 60,000 lung counts and 940,000 liver counts. Calculate 60,000 divided by 1,000,000 to obtain a lung-shunt fraction of 0.06, or 6%, then interpret it within the full dosimetric assessment.
Common pitfall: Dividing lung counts by liver counts alone uses the wrong denominator; treating the resulting percentage as a universal treatment cutoff confuses calculation with eligibility.
57.Which patient and liver characteristics determine suitability for chemoembolisation?
Transarterial chemoembolisation combines local chemotherapy delivery with arterial embolisation. For HCC, assess selected unresectable liver-confined disease after considering transplantation, resection and ablation. The 2025 EASL guideline supports evaluating whether tumour distribution permits selective treatment, together with preserved portal flow, liver function and performance status. Selected liver-confined disease suitable for selective embolisation differs from extensive or infiltrative disease that may favour systemic treatment. Assess bilirubin, albumin, coagulation, ascites, encephalopathy, tumour burden and portal perfusion together. Decompensated liver disease or severely compromised portal flow increases the danger that arterial embolisation will precipitate liver failure. Selective delivery limits injury to uninvolved liver. Major hazards include hepatic decompensation, biliary injury, infection and nontarget embolisation into gastrointestinal or gallbladder branches.
Apply it
Two patients have technically accessible multifocal HCC. One has preserved liver function, no ascites, patent portal inflow and tumour distribution permitting selective treatment; the other has worsening jaundice, refractory ascites and poor portal perfusion. The first warrants assessment for selective chemoembolisation. In the second, the physiological cost of embolisation may exceed its tumour benefit despite equally accessible arteries. Extensive or infiltrative disease also warrants assessment for systemic treatment rather than assuming that liver-confined location alone establishes TACE suitability.
Common pitfall: Selecting treatment solely from tumour vascularity or liver-confined location ignores selective treatability and the functioning liver exposed to ischaemia. Expected postembolisation pain and fever also must not obscure progressive jaundice, organ dysfunction or persistent infection.
European Curriculum and Syllabus for Interventional Radiology — Third Edition · CIRSE Clinical Practice Manual · EASL_CPG_Management_HCC.pdf
58.How should radioembolisation mapping be interpreted for nontarget risk and delivery uncertainty?
Extrahepatic gastrointestinal activity on mapping can indicate an arterial pathway to stomach or bowel and a risk of radiation injury. SPECT/CT helps localise activity and distinguish concerning distribution from artefact or physiological free-tracer uptake. Correlate it with angiography and the intended catheter position. Technetium-99m MAA is a surrogate: particle properties, catheter position, injection conditions and arterial flow can differ during therapy. A favourable simulated distribution therefore does not guarantee the therapeutic tumour dose or eliminate the need for post-treatment distribution assessment.
Apply it
Mapping shows focal activity near the stomach despite a low lung-shunt fraction. Identify its anatomical cause before proceeding. If treatment subsequently requires a different catheter position, reassess both tumour coverage and gastrointestinal delivery pathways rather than assuming the original MAA distribution still applies.
Common pitfall: A satisfactory lung-shunt fraction addresses only one hazard. Treating MAA as an exact microsphere replica can conceal both gastrointestinal nontarget delivery and uncertainty in the actual tumour dose.
59.Which portal territory is embolised to enlarge the future liver remnant?
Portal vein embolisation redirects portal flow away from liver scheduled for resection toward the future liver remnant, promoting its hypertrophy. The embolised territory must match the planned resection, while remnant portal branches are preserved. Access-route selection balances procedural convenience against injury to the remnant. This is a preparation for surgery rather than indiscriminate portal occlusion. The decisive planning step is agreement on exactly which liver will remain and which branches supply it.
Apply it
A patient is planned for right hepatectomy with an inadequate left-liver remnant. Plan embolisation of the right portal territory while protecting left-sided portal inflow, confirming that the intervention matches the agreed surgical resection.
Common pitfall: Embolising branches supplying the intended remnant undermines the purpose of the procedure; choosing territory from tumour location alone can conflict with the actual surgical plan.
60.How are future liver remnant growth measures calculated and interpreted?
Let V0 and V1 be baseline and follow-up remnant volumes. Absolute growth is V1 − V0 in mL; relative growth is 100 × (V1 − V0)/V0, using baseline remnant volume as denominator. With a fixed reference liver volume R, remnant proportion is 100 × V/R. Its change is measured in percentage points, not relative percent. A defined kinetic measure can be the change in remnant proportion divided by elapsed weeks, expressed as percentage points per week. State the chosen formula because volume-per-time and relative-growth-per-time measures differ. None establishes functional adequacy without considering liver quality and functional reserve.
Apply it
A remnant grows from 300 to 390 mL over two weeks. Absolute growth is 90 mL and relative growth is 90/300 × 100 = 30%. With a fixed 1,500 mL reference liver volume, its proportion rises from 20% to 26%, a six-percentage-point increase. The defined proportion-based kinetic growth rate is 6/2 = 3 percentage points per week. Absolute volume growth rate is separately 45 mL/week. Reassess function and surgical suitability alongside these measurements.
Common pitfall: Calling the rise from 20% to 26% a 6% relative increase confuses percentage points with relative growth: the relative increase is 30%. Changing the reference denominator between scans also changes interpretation, and volume gain cannot be assumed to equal functional gain.
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Use the complete third-edition syllabus to map all six domains; use its traffic-light categories without converting them into invented percentages.
- Practise the chain from indication and alternatives to access planning, complications, aftercare and clinical outcome.
- Prioritise discriminating emergencies: threatened limb viability, infected urinary obstruction, septic collections and obstructive cholangitis.
- Explain embolisation through anatomy and flow: collateral backfilling, critical arterial branches, portal redirection and nontarget distribution.
- Separate measurement from interpretation: ABI reliability, lung-shunt arithmetic, viable tumour response and future liver remnant growth.
- Maintain breadth beyond familiar procedures, especially renal transplants, musculoskeletal biopsy planning, chemoembolisation selection and visceral ablation.
A practical preparation plan
1. Map your scope against the official syllabus
Review sections A–F of the February 2023 syllabus and mark topics you can explain, topics needing revision and competencies requiring practical confirmation. Add syllabus topics omitted from this selective guide to your study plan.
2. Build indication-to-follow-up explanations
For each procedure, explain the disease mechanism, patient selection, alternatives, contraindications, access anatomy, immediate hazards and follow-up endpoint. Use the clinical references to support management decisions rather than relying on topic headings alone.
3. Contrast closely related clinical states
Compare marginally threatened with immediately threatened limbs, type II with attachment-site endoleaks, biloma with cholangitis, high surgical risk with operative unsuitability, and visible ice coverage with a lethal ablation margin. Identify the cue that changes the next action.
4. Complete the independent question set
Answer each question before reading its explanation. For every error, record the missed cue and explain why each alternative was less appropriate. Do not interpret the score as an EBIR pass prediction.
5. Rehearse calculations and active recall
Calculate lung-shunt fraction with the correct denominator. For remnant growth, calculate absolute mL gain, relative percentage growth, percentage-point change with a stated reference volume and a time-based growth measure with explicit units. Assess functional adequacy separately. Use the flashcards to recall mechanisms aloud, then revisit weak concepts after increasing intervals.
6. Practise sequential clinical reasoning
Turn a familiar case into stages: initial assessment, new imaging, procedural findings and postprocedure deterioration. At each stage, state what changed and how it affects management, reflecting the curriculum's emphasis on clinical case reasoning.
Use your sample score as a starting point
The free set contains 20 original practice questions. It is a small learning sample, not an official examination or a validated pass prediction. Review each explanation and its source before moving to another topic.
Start the free sampleOfficial sources and updates
- CIRSE — About the EBIR exam
- CIRSE — Curricula
- European Curriculum and Syllabus for Interventional Radiology — Third Edition
- CIRSE Clinical Practice Manual
- IAEA — Quality Assurance and Optimization for Fluoroscopically Guided Interventional Procedures, 2025
- IAEA SSG-46 — Occupational Radiation Protection in Image-Guided Interventional Procedures
- American Society of Anesthesiologists — Standards for Basic Anesthetic Monitoring
- 2024 AHA/ACC Peripheral Artery Disease Guideline — Official Slide Set
- CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair
- CIRSE Standards of Practice on Bronchial Artery Embolisation
- North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension
- CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms
- Society of Interventional Radiology Publishes IVC Filter Guidelines
- Korean Society of Thoracic Radiology — 2020 Clinical Practice Guideline for Percutaneous Transthoracic Needle Biopsy
- CIRSE Standards of Practice for the Provision of Emergency IR Care on a 24/7 Basis, 2026
- CIRSE Standards of Practice on Oesophageal and Gastroduodenal Stenting
- European Association of Urology — Urolithiasis Guidelines
- CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange, 2026
- British Sarcoma Group — UK Guidelines for the Management of Bone Sarcomas, 2024
- CIRSE Standards of Practice on Thermal Ablation of Bone Tumours
- EANM Procedure Guideline for the Treatment of Liver Cancer and Liver Metastases with Intra-Arterial Radioactive Compounds
- CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation
- Exam structure
- EBIR_Marks_and_Standards_2026.pdf
- PIIS1051044320305315.pdf
- Client Challenge
- ESUR guidelines on Contrast Media - B. Renal adverse reactions
- Client Challenge
- Client Challenge
- Client Challenge
- Client Challenge
- EASL_CPG_Management_HCC.pdf
Confirm current eligibility, fees, scheduling and policies directly with the examination provider. CertMedbry is independent and is not endorsed by these organisations. How we handle content and corrections.