Interventional Radiology

- This EPA focuses on effective communication with the patient and/or family in the discussion of consent for a common image-guided procedure. - This includes describing the alternatives to and benefits, risks, and expected outcomes of the procedure, including common risks as well as rare but serious risks. - It also includes responding to any questions and seeking out help or resources to answer questions prior to completion of consent. - Examples of common procedures are venous access insertion (e.g., port), angioplasty/stenting, IVC filter insertion, and tube insertion (nephrostomy, biliary drainage, etc.)

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure: venous access insertion; angioplasty/stenting; IVC filter insertion; tube insertion (e.g., nephrostomy, biliary drainage, etc.); other (write in) Collect 2 observations of achievement - At least 1 venous access insertion - At least 1 other procedure

Suggested observations: 2

- This EPA focuses on safe participation in an image-guided procedure including setting up for the procedure, maintaining sterility, adhering to universal precautions and radiation safety procedures, using the imaging equipment, and providing basic assistance in the procedure (e.g., flushing catheters, wire management).

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure type: arterial; other (write in) Collect 3 observations of achievement - At least 1 arterial procedure - At least 2 different observers

Suggested observations: 3

- This EPA focuses on the role of the physician as a member of the interprofessional clinical team. - This includes contributing to the work of the team, understanding and respecting the roles of other team members, and demonstrating appropriate professional behaviours. - It also includes effectively communicating with team members, both in writing and orally, to contribute to the shared safe care of the patient. - The observation of this EPA is based on a period of time of at least a day.

Direct or indirect observation by supervisor with input from other team members Use Form 1. Form collects information on: - Includes input from (select all that apply): supervisor; nurse; technologist; administrative staff ; other (write in) - Clinical setting: intraprocedural; other - Type of interaction: oral; written Collect 3 observations of achievement - At least 2 different team members providing input - At least 2 different supervisors - At least 1 intraprocedural setting - At least 1 other clinical setting - At least 2 oral interactions - At least 1 written interaction

Suggested observations: 3

- This EPA includes assessing requests from referring physicians, determining the urgency of the procedure, identifying what needs to be done to organize the procedure, optimizing the patient for the procedure (e.g., ordering additional blood work and/or imaging), and arranging the logistics, resources, and/or other services needed in order to safely perform the procedure.

Direct observation or case review by supervisor or TTP resident Use Form 1 Collect 3 observations of achievement - At least 3 different observers

Suggested observations: 3

- The focus of this EPA is the appropriate use of periprocedural medications and adherence to institutional guidelines. - This includes selecting medications and doses appropriate to the patient and the procedure, and anticipating and monitoring for adverse effects of the medication during the procedure and recovery. - Examples of medications include anxiolytics, analgesics, anticoagulants, antiplatelet agents, thrombolytics, antimicrobials, and reversal agents.

Direct observation by supervisor Use Form 1. Form collects information on: - Medication (select all that apply): analgesic; anticoagulant; antimicrobial; antiplatelet agent; anxiolytic; reversal agent; thrombolytic; other (write in) Collect 3 observations of achievement - At least 1 analgesic - At least 1 anticoagulant - At least 1 antimicrobial - At least 1 anxiolytic

Suggested observations: 3

- This EPA focuses on the application of knowledge and technical skills to perform simple image-guided procedures. - This applies to biopsies, drainage procedures (e.g., abscess drainage, simple pigtail chest tube), tube changes, venous and arterial access, and obtaining arterial hemostasis. - It includes reviewing prior imaging, planning for the procedure and needed equipment, documenting consent, performing the procedure, reporting the procedure, and recognizing complications and either managing them or seeking assistance.

Direct observation by supervisor Use Form 1. Form collects information on: - Modality: CT; fluoroscopy - non-vascular; fluoroscopy – vascular; ultrasound - Procedure (select all that apply): biopsy; drainage (e.g., simple pigtail chest tube, abscess drainage); tube change; tunneled venous access; femoral arterial access; radial arterial access; obtaining arterial hemostasis Collect 8 observations of achievement - At least 1 CT - At least 1 fluoroscopy - non-vascular - At least 1 fluoroscopy – vascular - At least 1 ultrasound - At least 1 biopsy - At least 1 drainage - At least 1 tube change - At least 1 tunneled venous access - At least 1 femoral arterial access - At least 1 radial arterial access - At least 1 obtaining arterial hemostasis

Suggested observations: 8

- An interventional radiology consultation entails a face-to-face assessment in the described setting (i.e., inpatient, outpatient, emergency department) prior to the proposed procedure. - This EPA focuses on integrating the clinical assessment and investigations to evaluate available treatment options and procedural risk, and share recommendations for interventional management with the patient and/or family. - It may include arranging for additional investigations and/or referrals as needed.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Setting: inpatient; outpatient; emergency department Collect 6 observations of achievement - At least 2 inpatient consultations - At least 3 outpatient consultations - At least 1 emergency department consultation

Suggested observations: 6

- With this EPA, the interventional radiologist applies their expertise in vascular imaging as it pertains to Interventional Radiology. - This includes assessing image quality, applying a systematic approach to image review, integrating findings with the clinical information and prior imaging studies, establishing a most likely diagnosis and a differential diagnosis, providing recommendations for management, and providing a report. - It includes MRI, CT, and ultrasound imaging modalities.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Modality (select all that apply): CTA; MRA; arterial US; CTV; MRV; venous US - Imaging focus: arterial; venous Collect 12 observations of achievement - At least 6 CTA - At least 2 MRA - At least 2 arterial US - At least 2 with venous focus

Suggested observations: 12

- This EPA includes reviewing clinical information and prior imaging tests, determining appropriateness of the procedure, reviewing or obtaining informed consent, reviewing the technical plan and equipment and devices needed for the procedure, reviewing and adjusting medication(s) as needed, and ensuring appropriate radiation protection protocols are in effect.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Observation: direct; case review - Procedure: ablation; embolization; arterial angioplasty/stenting; other (write in) Collect 4 observations of achievement - At least 1 direct observation - At least 1 ablation - At least 1 embolization - At least 1 arterial angioplasty/stenting

Suggested observations: 4

- This EPA includes assessing the patient’s recovery from the procedure, counselling patients and/or families about post-procedural care and when to seek medical assistance, and arranging appropriate follow-up including any needed post- procedural medication changes and investigations. - It may include handing over the care of patients to other health care providers, including direct communication about urgent issues as needed.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Observation: direct; case review - Type of case: interventional oncology; uterine fibroid embolization; arterial angioplasty/stenting; other (write in) Collect 4 observations of achievement - At least 1 direct observation - At least 1 interventional oncology case - At least 1 uterine fibroid embolization - At least 1 arterial angioplasty/stenting

Suggested observations: 4

- This EPA focuses on the application of written communication skills in a variety of formats: consultations; procedure notes; progress notes; documentation of a complication. - This includes generating accurate concise documents, in a timely manner, that provide a synthesis of the findings and/or procedure, are well-organized, and convey the rationale for decisions that were made or steps that were taken. - The documents submitted for review must be the sole work of the resident.

Document review by supervisor Use Form 1. Form collects information on: - Format: consultation for interventional oncology; consultation for uterine fibroid; consultation – other; documentation of a complication; procedure note; progress note Collect 6 observations of achievement - At least 1 consultation for interventional oncology - At least 1 consultation for uterine fibroid embolization - At least 1 documentation of a complication - At least 1 procedure note - At least 1 progress note

Suggested observations: 6

- This EPA builds on the technical skills attained in Diagnostic Radiology and includes a wide variety of procedures that are complex due to location, target characteristics, patient factors, or materials required. - This applies to the following procedures: biliary (drainage, stenting, cholecystostomy); genitourinary (drainage, stenting); gastrointestinal (gastrostomy, gastrojejunostomy, cecostomy, jejunostomy); gynecologic fertility (HSG, FTRs); tunneled drainage catheters (peritoneal, pleural); and, visceral cyst (sclerotherapy). - It includes positioning the patient, preparing the equipment, providing sedation/analgesia, visualizing relevant structures, performing the procedure (adapting it as needed), verifying the technical outcome of the procedure, and, as relevant, handling samples obtained and securing drainage devices.

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure: gastrostomy/gastrojejunostomy; gynecologic fertility procedure; nephrostomy; transhepatic biliary drain/stent; tunneled drain insertion; other (write in) Collect 8 observations of achievement - At least 2 gastrostomy/gastrojejunostomy procedures - At least 2 nephrostomy procedures - At least 2 transhepatic biliary drain procedures - At least 1 tunneled drain insertion

Suggested observations: 8

- This EPA focuses on the technical skills of access, guidewire manipulation, device placement and removal, angioplasty and balloon dilation, and stent deployment. - This includes placement of complex venous access devices (e.g., lines, ports) and dialysis access related interventions (line placement and removal, venous recanalization, angioplasty of fistulas and grafts). - It includes positioning the patient, preparing the technical devices and equipment, providing sedation, obtaining vascular access, visualizing relevant structures, performing the procedure adapting it as needed, verifying the technical outcome of the procedure, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Type of procedure: fistuloplasty; insertion of central venous catheter; insertion of central venous port; venoplasty; venous recanalization; venous sampling; venous stenting - Complex: yes; no Collect 6 observations of achievement - At least 2 fistuloplasty procedures - At least 2 insertions of central venous port - At least 1 other procedure - At least 1 complex procedure

Suggested observations: 6

- This EPA focuses on the technical skills of IVC filter placement and retrieval (simple and complex) or retrieval of other foreign bodies.

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure: IVC filter insertion; IVC filter retrieval; retrieval of other foreign body Collect 2 observations of achievement - At least 1 IVC filter placement - At least 1 IVC filter retrieval

Suggested observations: 2

- This EPA focuses on the technical skills applied in the assessment and improvement of arterial flow in visceral, peripheral, and aortoiliac vessels, including catheter and guidewire manipulation, angioplasty, and stent and stent graft deployment. - It includes positioning the patient, preparing the technical devices and equipment, providing sedation, obtaining vascular access, performing the angiogram, selecting the method +/- device for revascularization, performing the revascularization +/- deploying the device, verifying the technical outcome of the procedure, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Intervention (select all that apply): aortoiliac intervention; peripheral intervention; visceral intervention Collect 6 observations of achievement - At least 1 aortoiliac intervention - At least 1 peripheral arterial intervention - At least 1 visceral arterial intervention

Suggested observations: 6

- This EPA focuses on the technical skills of treating arterial and venous thrombosis, including pulmonary and systemic arteries, deep venous and portal vein thrombosis, and occluded dialysis fistulae and grafts. - This includes positioning the patient, preparing the equipment, obtaining vascular access, navigating to the vessel and obtaining visualization, selecting the device/agent for thrombectomy or thrombolysis, deploying the device and/or injecting the thrombolytic agent, verifying the technical outcome, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Presentation: arterial thrombosis; deep venous thrombosis; pulmonary embolism; portal vein thrombosis; occluded dialysis fistula or graft - Method: mechanical; pharmacologic; both Collect 2 observations of achievement - At least 2 different presentations - At least 1 mechanical method - At least 1 pharmacological method

Suggested observations: 2

- This EPA focuses on the technical skills of performing an embolization procedure, in a variety of sites. - Examples of conditions treated by these techniques include bleeding, visceral artery aneurysm, pseudoaneurysm, vascular malformation, varicocele, pelvic congestion, lymphatic leaks, and endoleaks. - The EPA includes positioning the patient, preparing the equipment, providing local anesthesia, obtaining vascular access, navigating to the appropriate site, delivering the embolic agent, verifying technical outcome of the procedure, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Embolic agent (select all that apply): coils/plugs; particles; gelfoam; liquid embolic - Site (select all that apply): arterial; venous; lymphatic - Active bleeding: yes; no - Microcatheter: yes; no Collect 6 observations of achievement - At least 1 coils/plugs - At least 1 particles - At least 1 gelfoam - At least 1 liquid embolic - At least 2 different sites - At least 2 active bleeding - At least 3 using microcatheter

Suggested observations: 6

- This EPA focuses on the technical skills of treatments for patients with any soft tissue, bone, or organ-based tumour (benign or malignant), including ablations and bland embolization, chemoembolization (TACE), and radioembolization (TARE). - This includes positioning the patient, preparing the technical devices and materials, providing local anesthesia and obtaining access to the target lesion, performing the ablation/embolization, adapting the procedure as needed, verifying technical outcome of the procedure, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Technique: ablation-kidney; ablation-liver; bland embolization-kidney; bland embolization-liver; bland embolization-uterus; TACE-liver or TARE-liver; other (write in) Collect 8 observations of achievement - At least 2 ablations of the liver - At least 2 ablations of the kidney - At least 2 embolization of the uterus - At least 2 TACE or TARE of the liver

Suggested observations: 8

- This EPA focuses on applying knowledge of the unique physiology of portal hypertension as well as technical skills to perform transjugular biopsy and pressure measurements, transjugular intrahepatic portosystemic shunt (TIPSS) creation and management, and portosystemic shunt management. - This includes positioning the patient, preparing the equipment, providing sedation, obtaining access to the target vessel, performing the procedure (adapting it as needed), utilizing experienced assistants when indicated, and ensuring access hemostasis.

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure: transjugular biopsy and pressure measurements; TIPSS; portosystemic shunt management Collect 2 observations of achievement - At least 1 transjugular biopsy and pressure measurements - At least 1 TIPSS

Suggested observations: 2

- This EPA focuses on the technical skills of injections (epidural, MSK and appendicular), nerve and facet blocks in the axial skeleton, plexus blocks (celiac, hypogastric, splanchnic, cervical, lumbar, ganglion impar, stellate ganglion), and cement augmentation (vertebroplasty, kyphoplasty, long bone). - It also includes monitoring the pain response pre- and post-procedure and responding to any unanticipated circumstances arising during the procedure.

Direct observation by supervisor Use Form 1. Form collects information on: - Procedure: cement augmentation; epidural injection; facet block; joint injection; nerve block; plexus block; other (write in) Collect 3 observations of achievement - At least 2 different procedures

Suggested observations: 3

- This EPA includes recognizing when a complication has occurred during or as a result of an image-guided procedure, stabilizing the patient, and either managing the complication directly or arranging for another physician/service to address the problem, and organizing appropriate patient disposition and follow-up. - It may include disclosure and communication to the patient and family, if relevant. - Examples of complications include bleeding, allergic reaction, oversedation, hemodynamic instability, dissection, thrombosis, pneumothorax, perforation, non-target embolization, cardiac arrest, loss of access, and equipment failure. - Minor and major complication definitions refer to the Society of Interventional Radiology adverse event classifications.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Observation: direct; case review - Timing: intraprocedural; periprocedural; delayed - Classification: minor complication; major complication Collect 3 observations of achievement - At least 1 direct observation - At least 1 intraprocedural - At least 1 periprocedural - At least 1 delayed - At least 1 major complication

Suggested observations: 3

- This EPA integrates procedural abilities for individual cases with the ability to work effectively in the interventional suite: managing the workflow, staying on schedule, ensuring safety measures are followed, monitoring and adjusting room and equipment set up, working effectively with the team, and performing the list of procedures. - An important aspect of this EPA is working within one’s limits and asking for assistance when needed. - Observation of this EPA is based on managing a full day’s list.

Direct or indirect observation by supervisor with input from other team members Use Form 1 Collect 2 observations of achievement - At least 2 different observers

Suggested observations: 2

- This EPA focuses on the IR subspecialist’s role in the overall delivery of safe patient care, maintaining the volume and quality of the service. - This includes: prioritization and scheduling of cases; adapting the day’s schedule to changes in health human resources, patient flow and/or arising urgent cases; allocating learner assignments; responding to calls and requests from other physicians; and protocolling future procedures. - It also includes working effectively with the interprofessional team, coordinating patient disposition, and applying time management skills to simultaneously fulfil multiple clinical responsibilities. - The observation of this EPA is based on a day’s work.

Direct and indirect observation by supervisor with input from members of interventional radiology team Use Form 1 Collect 2 observations of achievement - At least 2 different supervisors

Suggested observations: 2

- This EPA focuses on the role of the interventional radiologist as the authority providing interventional radiology expertise in a multidisciplinary team discussion. - This includes preparing for the discussion by reviewing imaging and identifying image- guided treatment options, anticipating challenges to the IR approach and formulating a management plan, contributing to the discussion about treatment options, advocating for the patient, and demonstrating professional behaviour.

Direct observation by supervisor with input from other clinicians Use Form 1. Form collects information on: - Setting: multidisciplinary rounds; morbidity and mortality rounds; other (write in) Collect 2 observations of achievement - At least 1 multidisciplinary rounds - At least 2 different supervisors

Suggested observations: 2

- This EPA focuses on the teaching that occurs in the interventional radiology suite, and includes ensuring safe patient care, teaching, and providing feedback. - This includes supervising and teaching medical students and other residents.

Direct observation by supervisor, incorporating feedback from learners Use Form 1. Form collects information on: - Type of learner (select all that apply): medical student; IR resident; other resident Collect 2 observations of achievement - At least 2 different types of learners - At least 2 different supervisors

Suggested observations: 2

- This EPA includes all relevant aspects of performing scholarly work: identification of a question for investigation, literature review, project design, ethics approval, data gathering, data analysis, reflective critique, and dissemination. - This may include scholarly activities related to clinical or basic science research, patient safety, quality improvement or education scholarship. - Assessment is based on the submission of a completed scholarly project and may also include observation of the presentation of the scholarly work at a local, national, or international meeting.

Review of presentation or submitted project by supervisor Use Form 4 Collect 1 observation of achievement

Suggested observations: 1