For the clinical review

Clinical questions

These are clinical decisions we did not want to make for you. Each one says what the guide says now, so most can be answered “keep” or “change to ...”. No safety advice was moved between groups while writing.

All guides

• ALL-1. Frequency scale. Every risk now starts with one word from one scale: Very common (more than 1 in 10), Common (1 in 10 to 1 in 100), Uncommon (1 in 100 to 1 in 1,000), Rare (1 in 1,000 to 1 in 10,000), Very rare (fewer than 1 in 10,000). A range that spans two bands takes the band of the larger number. A number exactly on a line takes the more frequent band (1 in 100 is Common, 1 in 1,000 is Uncommon), except 1 in 10, which the scale puts in Common. Please confirm.
• ALL-2. Labels that may surprise readers under this scale. Risk to life is now “Common” in EVAR (HealthLink BC gives 1 to 2 in 100) and in the biliary drain guide (an older guideline gives 1.7 in 100). Nephrostomy infection is now “Very common” because one leaflet gives 1 in 10 to 1 in 2 for any spreading infection. TACE liver failure is now “Common” (about 1 in 100). Please confirm these are the numbers you want shown.
• ALL-3. Fever threshold. EVAR says 37.8 °C; PICC, TACE and biliary say 38 °C; UFE, PAE, vertebroplasty, nephrostomy and varicose give no number. Should every guide use one house threshold?
• ALL-4. Bleeding or a growing lump at the puncture site. UFE and TACE put a fast-growing lump or bleeding that will not stop under 9-1-1; EVAR puts a fast-growing groin lump under 9-1-1 but “bright red blood soaking through the dressing” under the IR team; PAE puts “a painful lump that keeps growing” under the IR team; varicose puts “bleeding from the small opening” under the IR team. Please set one rule.
• ALL-5. Benefits and risks in one form. Benefits are written “in 10” (for example UFE: “About 8 or 9 in 10 people say their symptoms get much better”), while risks use “in 100”, “in 1,000” and “in 10,000”. A site review (17 October 2026) suggested writing benefits the same way as the risks, for example “80 to 90 in 100”. No number was changed. Keep “in 10”, or change?
• ALL-6. How much bleeding means a call. Some warning signs name bleeding without a measure: UFE “Heavier bleeding from the vagina”, biliary “Heavy bleeding”, nephrostomy “Heavy bleeding from the tube or from the skin around it”. A site review suggested a measure a patient can check, for example how many pads are soaked in an hour. Should the guides give one, and what is it? No measure will be added until you give one. (The fever threshold is ALL-3.)

UFE (uterine fibroid embolization)

• UFE-1. Tier: “Heavier bleeding from the vagina” and “Severe pain in your belly or pelvis” are under “Call the IR team the same day”. Should either be 9-1-1 or the emergency department?
• UFE-2. No opened source gives a fever temperature for when to call. Please add yours.
• UFE-3. The 9-1-1 list and “A painful, swollen leg” are standard safety advice built from the sourced risks (clots, dye reaction, stroke with the wrist route, infection). No UFE leaflet lists them word for word. Please confirm the list.
• UFE-4. The dye reaction rate (about 6 in 1,000; serious about 4 in 10,000) is for iodinated contrast in general, not from a UFE study. Use your own figure if you prefer.
• UFE-5. No source gives a rate for stroke with the wrist route or for particles reaching the wrong place. The guide says “Rare” for particles in the wrong place (sources say “rarely” and report single cases). Please confirm the word.
• UFE-6. Cramps, low fever, nausea and tiredness are now described in Recovery as expected (“most people”). The risk list keeps only the complication form: about 3 in 100 in trials. Please confirm that split.
• UFE-7. Local practice that an earlier draft stated but the opened sources did not support: most people home the same day, no general anaesthetic, about a week to feel normal, a wrist band for a few hours, about 30 minutes in the procedure room. The guide uses the sourced ranges instead. Confirm or supply your own.
• UFE-8. The name of one risk. “Cramps, fever and nausea afterwards” is listed as a risk (the complication form, about 3 in 100 in trials), but milder cramps, a low fever and nausea are expected in recovery (UFE-6). A site review suggested a name that shows it is the stronger form, so readers do not think the expected cramps are a complication. Keep the name, or change it to what?
• UFE-9. Stroke signs. The 9-1-1 list gives three stroke signs on separate lines: “Sudden weakness or numbness”, “A drooping face” and “Trouble speaking”. A site review suggested one line instead. Keep three lines, or join them?

EVAR (endovascular aneurysm repair)

• EVAR-1. Tier: “A cold foot, or a toe that turns blue or black” (a possible blocked graft leg) and “Bright red blood soaking through the dressing” are under “Call the IR team”, not 9-1-1. “Swelling, pain or redness in a leg (this can be a blood clot)” is also under the IR team.
• EVAR-2. The fever line says over 37.8 °C (from a Healthwise aftercare page). Other guides use 38 °C.
• EVAR-3. Frequency boundaries: a late burst at about 1 in 75 is “Common”; death around the time of repair is “Common” (1 to 2 in 100 from HealthLink BC, fewer than 1 in 200 in a patient leaflet).
• EVAR-4. The type I leak figure (about 8 in 100) comes from one hospital’s cohort of repairs done from 2006 to 2012. No multi-centre rate was found.
• EVAR-5. Warning signs of a blocked graft leg (for example pain when walking) were not found in any opened source, so only the cold foot or blue toe line is in the guide.
• EVAR-6. The size threshold for repair in women is still unsourced in the patient copy. A 2022 J Vasc Surg paper (PMC8963251) reports society suggestions of 5.0 to 5.4 cm, if you want it added.
• EVAR-7. Some numbers rest only on one NHS hospital leaflet: “about 15 in 100 need another procedure within 4 years” (NICE’s decision aid says about 20 in 100 by 4 years) and death “fewer than 1 in 200” (the UK National Vascular Registry gives 0.5 in 100 in hospital, about 1 in 200). Which figures do you want shown?
• EVAR-8. Lifting (4 to 6 weeks), driving (when you can do an emergency stop without pain and are off pain medicine), an ECG before the procedure, and the first check-up at about 6 weeks come only from hospital leaflets. Please confirm against your own instructions.

PAE (prostate artery embolization)

• PAE-1. Tier: “You cannot pee at all” is under “Call the IR team”. The old bullet said “get help right away”; it now says “(this is urgent)”. Should it be 9-1-1 or the emergency department?
• PAE-2. Tier: “A painful lump at the groin or wrist that keeps growing” and “Bleeding from the penis” are under the IR team. Other guides put a fast-growing lump under 9-1-1.
• PAE-3. The 9-1-1 bleeding advice (lie down and press hard for 10 minutes) and parts of the call list come from two UK hospital leaflets listed only in the internal brief. Please confirm against your discharge instructions.
• PAE-4. No source gives a rate for bleeding or artery injury at the entry point, or for bladder wall harm or lasting rectal harm on their own.
• PAE-5. When men can drive, work and have sex again: sources differ (next day, 1 week, 1 to 2 weeks). The guide says to ask the team.
• PAE-6. “Trouble peeing” is 5 to 8 in 100 in studies, but one patient leaflet calls it rare.

Vertebroplasty and kyphoplasty

• VERT-1. Tier: “New numbness or tingling” is under the IR team, while “New weakness in your legs” and loss of bladder or bowel control are 9-1-1. Cement pressing on a nerve can need an urgent operation. Please confirm the split, and the whole 9-1-1 / IR team / 8-1-1 split.
• VERT-2. No rate was found for rib fracture.
• VERT-3. Fasting and blood thinner timing differ between sources (food 6 hours and drinks 2 hours before, or nothing from the night before; blood thinners “several days” to at least 5 days). Please replace with your own instructions.
• VERT-4. The CIRSE 2017 and SIR 2014 clinical guidelines were not opened.
• VERT-5. The benefit line “about half to 9 in 10” combines three patient guides that measured different things, and both ends come only from hospital leaflets.
• VERT-6. Both “about 1 in 500” figures (cement pressing on a nerve or the spinal cord; breathing problems from cement in the lungs) come only from one NHS hospital leaflet. In one series, 1 of 616 people needed an operation for cement in the spinal canal (about 1 in 600). No source gives a rate for breathing problems. Please confirm or supply your own figures.

Nephrostomy

• NEPH-1. Tier: “Bright red urine, like beet juice” is under the IR team (same day), while “Heavy bleeding from the tube or from the skin around it” is 9-1-1. “The tube falls out or slips” is a same-day IR team call. Please confirm.
• NEPH-2. No fever temperature is given in the patient copy (one leaflet in the brief uses 38.3 °C).
• NEPH-3. The dye reaction is not in the risk list because no source gives a rate for contrast injected into the kidney. Supply one if you want it listed.
• NEPH-4. Widening the track with dilators is not described, because no opened source supports it for a standard drainage tube. Supply a source if you want it in.
• NEPH-5. Infection numbers differ by what is counted: septic shock 1 to 10 in 100 (SIR), 1 to 3 in 100 (review); any spreading infection 1 in 10 to 1 in 2 (BAUS leaflet). The label is now “Very common” because of the BAUS figure.
• NEPH-6. Bath advice differs between sources. The guide says no bath.
• NEPH-7. Tier: BAUS, CAIR and MedlinePlus say to contact the team immediately if the tube falls out, or for fever, leaking or no drainage. The guide says to call the IR team the same day. Please confirm.
• NEPH-8. Some home-care advice comes only from NHS trust leaflets: empty the bag at half to two-thirds full, drink an extra half litre if it stops draining, avoid hard exercise and contact sports, cover the hole if the tube falls out, and tell the nurse before you get up. Please confirm against your own instructions.

PICC

• PICC-1. Tier: heavy bleeding is not in the 9-1-1 list (no source puts it there). “Swelling of your arm, shoulder, chest, neck or face on the side of the line” (a possible clot) and “The line leaks, cracks or is cut” (air can get in) are under the IR team or care team. Please confirm.
• PICC-2. “Tip in the wrong place” is labelled Uncommon because none of 100 lines placed with live X-ray were misplaced in one study. 100 lines cannot show a rate under 1 in 100.
• PICC-3. “Line cracks” is now labelled Common (about 4 in 100 in one chemotherapy study), though patient guides call cracks uncommon or very rare.
• PICC-4. No rates were found for air getting into the vein, late heartbeat changes, or harm to veins needed for dialysis.
• PICC-5. How breast cancer, armpit lymph node removal or a pacemaker changes which arm is used is not stated in any source.
• PICC-6. Bathing and swimming advice conflicts (CDC: never submerge; Cancer Research UK and Macmillan: a covered bath is fine).
• PICC-7. “Do not push a slipped line back in” was found only in a local hospital handout and is not in the guide.
• PICC-8. Some advice comes only from US hospital pages: no shower for 24 hours, no needles in that arm, no push-ups, a 5 lb (2.3 kg) lifting limit, and a pacemaker or uneven heartbeat as conditions to tell the team. Please confirm against your own instructions.

TACE (transarterial chemoembolization)

• TACE-1. Tier: “Shortness of breath” is under the IR team, while “Bad trouble breathing” is 9-1-1. Where is the line?
• TACE-2. The 9-1-1 list (sudden severe belly pain, fainting, chest pain, bad trouble breathing, vomiting blood, bleeding that will not stop, a fast-growing lump) is general emergency advice. No TACE source gives this exact list.
• TACE-3. Warning signs of liver failure at home (yellow skin or eyes, confusion) are not in the call list because no opened source lists them.
• TACE-4. “A fever that lasts more than a week” is inferred from a source saying a fever for up to a week is normal.
• TACE-5. Not found in sources: exact days to stop blood thinners; how often the wrist route is used; routine use of a microcatheter; rates of chemotherapy side effects in the rest of the body; how well TACE works for cancer that spread to the liver.

Biliary drain (PTBD)

• BIL-1. Tier: “Heavy bleeding” and “New blood in the bag” are under “Call the IR team right away” (as in the source leaflet). Should heavy bleeding, or fever with confusion, be 9-1-1?
• BIL-2. Most rates for sepsis, chest problems, belly problems and death come from a 2003 guideline (1997 data) and one single-centre series. The 2020 SIR and 2021 CIRSE standards could not be opened in full. Please check for newer figures.
• BIL-3. Pancreatitis is labelled Common on one centre’s 1.2 in 100; studies range from about 1 in 200 to 6 in 100.
• BIL-4. Fever threshold: one leaflet says 38 °C, another 38.3 °C. The guide uses 38 °C.
• BIL-5. What to do if the drain falls out (cover the site, do not push it back) was not found in an opened source, so the guide does not say it.
• BIL-6. The whole 9-1-1 list, the 38 °C fever line and most daily drain care (flush volume, dressing schedule, showering, 4.5 kg lifting) come only from two US hospital patient guides. A government aftercare page (MyHealth Alberta) lists a loose tube and a sudden change in the colour or smell of the drainage as reasons to call now; the guide does not list the colour or smell change. Please confirm against your own discharge sheet.

Varicose vein treatment (endovenous ablation)

• VAR-1. Tier: “A leg, foot or toes that are cold, pale, blue, numb or tingly” and “Bleeding from the small opening where the tube went in” are under the IR team. Compare EVAR, where similar signs are also under the IR team.
• VAR-2. The aftercare source also lists vision or balance problems as a reason to call now. This is not in the guide. Add it?
• VAR-3. Not found in sources: fasting rules; whether a blood thinner is given routinely after ablation; a fever temperature; how far below the groin heating starts; a skin burn rate on its own; a 5-year recurrence rate.
• VAR-4. The consent form at arrival is described as standard practice, with no source.
• VAR-5. “Some teams say to wait 2 weeks” before flying, “laser heating about 3 to 5 minutes” and “keep the small opening clean and dry” come only from one US hospital page. “Cold” and “pale” in the leg warning sign come only from a US edition of the aftercare page. Please confirm.

What the 3D guides show

Each step of a 3D guide now acts itself out on the model while its sentence is highlighted: the catheter travels, dye lights the vessels, particles flow in and the vessels go pale. Every animation shows only what its sentence says, but some are simplifications. Please answer “fine” or “change to ...” and quote the number.

All guides

• 3D-ALL-1 Normal blood flow is shown as a warm red wave that passes and fades; X-ray dye is an ivory wave that leaves the vessels softly lit. Urine is shown in pale yellow. Is the difference clear enough?
• 3D-ALL-2 A blocked vessel is shown turning pale from the catheter tip onward (downstream only), stopping before side branches such as those toward the ovary. Acceptable as a simplification?

UFE

• 3D-UFE-1 Access is shown at the patient’s right groin; the catheter crosses over to the left uterine artery first, then is withdrawn and steered into the right uterine artery. Fine as a typical sequence?
• 3D-UFE-2 Particles are shown streaming from the catheter tip and lodging along the branches of the uterine artery that feed the fibroid; the fibroid then dulls. Fine?
• 3D-UFE-3 After the procedure, the treated uterine arteries stay pale in the later steps. Fine?

PAE

• 3D-PAE-1 Only one coil is modelled (left, a branch toward the rectum). The text says “the same steps” are done on the other side, but no coil is shown on the right. Fine?
• 3D-PAE-2 The right side is reached by withdrawing the catheter and going back up and over the bifurcation, standing in for a reformed loop. Fine?
• 3D-PAE-3 The prostate arteries stay pale from blocking through “months later”. Acceptable?
• 3D-PAE-4 The first days show a subtle swelling of the gland (about 6%). Keep or drop?
• 3D-PAE-5 “About a quarter smaller” months later matches the model’s after prostate (about 27% smaller by volume). Is that a fair illustration, or should the label avoid a size?

EVAR

• 3D-EVAR-1 The model’s graft fabric top edge slightly overlaps the lower edge of the right kidney artery’s opening (visible in close-ups). Should the model be corrected before review?
• 3D-EVAR-2 The model’s normal aorta is about 2.7 to 2.9 cm wide against the text’s “about 2 cm”, so the label says “Normal width” with no number. Fine?
• 3D-EVAR-3 Only the right wire is shown going up during “getting in” (the text mentions one wire). A left catheter for the dye run is common. Show it?
• 3D-EVAR-4 The dye for the X-ray run starts at the wire tip at the top of the model, not from a pigtail catheter at the level of the kidney arteries. Fine as a simplification?
• 3D-EVAR-5 The balloon presses the top seal, then moves down to press the join where the second leg docks. Fine?
• 3D-EVAR-6 A year later the sac is shown about 12% narrower than on the day (the model was corrected from 28%). Fine?

Vertebroplasty and kyphoplasty

• 3D-VP-1 Is the “Pedicle” label point (about three quarters along the needle path) truly in the pedicle and not the lamina or facet?
• 3D-VP-2 Is “Spine tips forward” (on the bone above the wedge) the right way to describe the stoop?
• 3D-VP-3 “Spinal cord covering” points at the dural sac at the T12 to L1 disc level. Is that wording fine?
• 3D-VP-4 The kyphoplasty height gain appears when the cement goes in, not while the balloon inflates, and the cement is shown through the needle rather than the working tube. Acceptable?
• 3D-VP-5 Entry is shown through the patient’s left pedicle, about 15 degrees inward, with the tip stopping in the front half of the bone. Fine?

TACE

• 3D-TACE-1 The hepatic artery dye starts where the artery leaves the aorta, so the branch to the spleen lights too. Fine?
• 3D-TACE-2 The thin catheter stops about 1.4 cm before the tumour artery branches. Does that read as “as close to them as possible”?
• 3D-TACE-3 The model’s treated tumour is about the same size as before, so the change over weeks is shown as a duller colour, not shrinking. Fine, or should it shrink?
• 3D-TACE-4 The medicine (including the oily Lipiodol mix) is shown as a pale stream, and the blocking beads as amber particles. Fine?

Nephrostomy

• 3D-NEPH-1 The needle passes just below and outside the tip of the 12th rib into a lower-pole cup at the back of the kidney. Does this read correctly?
• 3D-NEPH-2 The wire coils toward the upper part of the collecting system and the tube’s loop sits in the funnel (renal pelvis). Fine?
• 3D-NEPH-3 “Large blood vessels” points at where the main artery and vein enter the kidney. Fine?
• 3D-NEPH-4 The kidney shrinks back to normal size as the urine drains, and the blockage stays in every after state. Fine?