Interventional Radiology · Periprocedural haemostasis · CIRSE 2021 / SIR 2019

CIRSE and SIR Bleeding-Risk Categories for Image-Guided Procedures

CIRSE and SIR procedure-associated bleeding-risk categories used to guide periprocedural haemostatic assessment and antithrombotic planning. The systems are not interchangeable: CIRSE uses three tiers, whereas the current SIR scheme uses two.

Purpose

To classify image-guided procedures by procedure-associated bleeding risk so that laboratory assessment and interruption or continuation of antithrombotic therapy can be planned alongside patient-specific thrombotic and bleeding risks.

Framework	Category	Procedure examples
CIRSE (2021)	Low bleeding risk	Pleural or ascites drainage; superficial drainage; superficial aspiration/biopsy of thyroid, breast or superficial lymph node; exchange of biliary, nephrostomy or abscess catheters; IVC filter placement; venography; dialysis-access interventions.
CIRSE (2021)	Moderate bleeding risk	Abdominal biopsy or drainage other than liver, kidney or spleen; gallbladder drainage; gastrostomy; biliary-drain exchange; angiography with access up to 7 F; chemoembolisation or radioembolisation; transjugular liver biopsy; uterine fibroid embolisation; spinal procedures.
CIRSE (2021)	High bleeding risk	Liver, kidney or spleen biopsy/drainage; biliary interventions; thermal ablation; nephrostomy; transjugular intrahepatic portosystemic shunt.
SIR (2019)	Low bleeding risk	Catheter exchanges; peripheral diagnostic arteriography or arterial intervention with sheath under 6 F; pelvic or extremity venography/select venous interventions; dialysis-access intervention; IVC filter placement or routine removal; lumbar puncture; non-tunnelled chest tube; venous access; paracentesis; thoracentesis; superficial biopsy/drainage; transjugular liver biopsy; tunnelled drainage or venous catheter procedures; selected peripheral, joint and thoracolumbar pain procedures.
SIR (2019)	High bleeding risk	Solid-organ, bone, soft-tissue or lung ablation; arterial intervention using a sheath over 7 F or involving the aorta, pelvis, mesentery or central nervous system; biliary intervention including cholecystostomy; catheter-directed thrombolysis; deep abscess drainage or deep non-organ biopsy; gastrostomy/gastrojejunostomy placement; complex IVC-filter removal; portal-vein intervention; solid-organ biopsy; spinal procedures carrying spinal/epidural haematoma risk; transjugular intrahepatic portosystemic shunt; urinary-tract intervention including nephrostomy; intrathoracic or central nervous system venous intervention.

How to use it

CIRSE retains low, moderate and high procedure categories; the 2019 SIR update replaced its former three-tier scheme with low and high categories.
SIR low-risk procedures are generally those in which major haemorrhage is uncommon or bleeding is readily detected and controlled; high-risk procedures include those with greater expected haemorrhage, difficult detection/control or severe consequences from even limited bleeding.
The two lists must not be mapped mechanically: for example, transjugular liver biopsy is low risk in SIR but moderate risk in CIRSE.
Patient comorbidity, antithrombotic therapy and anticipated technical complexity may increase the practical bleeding risk beyond the procedure label.
Use the chosen society framework consistently with its medication-specific recommendations and the current institutional protocol.

Common mistake

Do not quote the superseded SIR low/moderate/high scheme as current or merge the CIRSE moderate category into SIR without stating which framework is being used.

Exam pearl

The fastest discriminator is the number of tiers: CIRSE has three; current SIR has two. A useful viva example of non-equivalence is transjugular liver biopsy—moderate in CIRSE, low in SIR.

Viva questions

Why are image-guided procedures assigned a bleeding-risk category?: The category helps plan haemostatic laboratory assessment and periprocedural antithrombotic management. It must be considered together with the patient's bleeding and thrombotic risks.
What are the CIRSE procedure-associated bleeding-risk categories?: CIRSE uses three categories: low, moderate and high bleeding risk.
What categories are used in the current SIR scheme?: The 2019 SIR update uses two categories: low and high bleeding risk. It replaced the previous low, moderate and high scheme.
Why should the CIRSE and SIR categories not be merged?: They use different numbers of tiers and do not assign every procedure identically. The society and edition must therefore be stated whenever a category is quoted.
How is transjugular liver biopsy categorised by CIRSE and SIR?: It is moderate bleeding risk in the CIRSE table but low bleeding risk in the 2019 SIR table.
Name procedures classified as high bleeding risk in both frameworks.: Examples include thermal ablation, nephrostomy and transjugular intrahepatic portosystemic shunt creation.
What features make a procedure high bleeding risk in the SIR framework?: High-risk procedures may have a greater expected haemorrhage risk, occur where bleeding is difficult to detect or control, or take place where even limited bleeding can have severe consequences.
Can the procedure category alone determine antithrombotic management?: No. Patient comorbidity, the specific antithrombotic drug, thrombotic risk and anticipated technical complexity must also be assessed, using the current society or institutional protocol.