"This document was created from observing the presentations of residents and fellows in June and July 2025. It is meant to be a resource and guide, rather than a formula." -Tejal Gala , MD

I. Core Presentation Structure

1. One-liner

“(Name/age/gender) here for (procedure), history of (only state the relevant diagnoses or history. We want to communicate why we’re doing the procedure).”

2. Additional history, if applicable

• Have there been prior interventions to address the problem at hand?

• Any relevant imaging studies leading up to this procedure? What did the most recent show?

  • If yes, mention briefly, and in chronological order. We want to tell a relevant story with imaging findings that would be useful to know for today’s procedure.

• If there is a mass or fluid collection we will be accessing or treating today, what is its size on imaging? Where is it located? If in the liver, state the Segment(s).

• If a prior Y90 mapping was done, which vessel supplies the tumor? (Know the lung shunt fraction as well, but no need to say it during the presentation unless asked.)

• If we’re placing a line, has the patient had a line before and, if so, was it placed here or at an outside hospital (OSH)? What size/type of line was it? Which vessel was accessed (i.e. right IJ)? Any history of difficult line placements?

• If we’re placing a G or GJ tube, mention the size/type of tube we’re planning to place. If we’re exchanging it, mention if/when it was last exchanged and the patient’s current size/type of tube. If this is the first time we’re exchanging it, mention it if was placed here or at an OSH, and whether it was placed by VIR or surgery.

3. Procedure-specific details (if applicable)

• TIPS: MELD score, Child Pugh class, ECOG score, Echocardiogram (mention if/when it was done, along with the result)

• Y90 mapping or treatment: LI-RADS category, BCLC stage, Child Pugh class, ECOG score

• Prostate artery embolization: IPSS, QoL (the final item in the IPSS questionnaire)

4. Labs

“Labs ok” / “Need (i.e. CBC, INR, CMP)” – Orders in?

Generally, if the current labs are within 30d of the procedure, we do not need new labs.

5. Antibiotics

“No antibiotics” / “(i.e. Ancef 2g IV)” – Orders in?

If the patient has a penicillin allergy, mention it here, because it will likely affect our antibiotic choice.

6. Other pre-procedural medications

If there are any other pre-procedural medications mentioned in the VIR note or in the VIR Team Sticky Note (see “Resources” section), simply state “Pre-med orders in” (or “not yet in”). No need to list the pre-procedural medications.

7. Anticoagulation

“Not on anticoagulation” / “On ___, held since ___” (or “not holding prior to procedure”).

8. Positioning

“Supine / Prone / (R/L) side bump / (L/R) lateral decubitus / Frog leg”

• Bump or lateral decubitus position is sometimes used in percutaneous procedures to better access the target (i.e. if we’re taking a biopsy of a Segment 7 lesion, we may position the patient with the R side bumped or in L lateral decubitus)
  
  

• The frog leg position is typically used in two scenarios:

  1. Pulmonary AVM embolization procedures in patients with hereditary hemorrhagic telangiectasia (HHT). We do bilateral frog legs in order for the saline bowl to fit between the legs to facilitate exchanges “underwater,” which mitigates the risk of air emboli to the lungs or brain.

  2. Access (i.e. in a thrombectomy for a patient with extensive L lower extremity DVT, we may be considering a few access sites along the leg including the L posterior tibial vein, in which case the patient should be supine in L frog leg position.)

9. Prep

“Prep the (i.e. b/l groin, R neck, L wrist, abdomen)”

If we’re considering a L radial approach, has a Barbeau test or an ultrasound of the wrist been done? We may need/want to perform them before the procedure to ensure we can safely take a radial approach.

10. Other Procedure Planning Details

• Pre-ultrasound? We’ll do this for drains and biopsies, as well as in situations where we’re unsure which vessel we should access.

• Latex allergy or other relevant allergy?

Additional relevant details (from VIR notes or VIR Team Sticky Note):

• 2 IVs?

• Spin for cone-beam CT? (Tuck to spin if significantly elevated BMI)

• Specific embolic agents or devices we’re planning on using? ICE or IVUS? iGuide?

11. Specimen Handling

• Solid biopsy: specify the collection medium: Formalin, Telfa-Saline, something else? Are the Surg Path orders in?

• Fluid sample: specify whether cytology and lab orders are in.

12. Sedation Level

“Moderate sedation / general anesthesia”

II. Resources for Locating or Determining Presentation Details

1. The notes, imaging studies, labs, and orders in the chart will often provide all of the relevant information.

2. The pictorial icons in the Snapboard entries on the schedule can provide an immediate way to see if the patient is an outpatient (icon of a walking person) or if the procedure will be done under general anesthesia (icon of two faces with masks).

3. Sometimes, the residents and fellows write notes about the procedural technique in the VIR Team Sticky Note. This can be seen by clicking on an entry in the Snapboard → sidebar opens on the right side of the screen → type “VIR Rounding” in the search bar at the top of the sidebar. The VIR Team Sticky Note will now be visible in the sidebar.

4. The SIR Guidelines app → “Periprocedural guidelines” section provides information on if/when to hold anticoagulation and prophylactic antibiotic recommendations.

III. Final Notes

If you remain unsure of certain details, ask a resident, fellow, or attending beforehand, or go with your best judgment and use it as an opportunity to clarify.

Although this document might make it seem like you need to say a LOT of information during the presentation, err on the side of saying less and knowing more. The items written in bold are items you should definitely say during your presentation. If you’re not sure whether certain pieces of information are relevant to the procedure, don’t say them (we want to keep the presentation as brief as possible!), but do know them and write them down in case someone asks.

You’ll do great!