Prevention and management of bleeding complications in interventional ultrasound: an international expert consensus statement

Interventional ultrasound has become an essential minimally invasive modality in modern medicine, encompassing biopsy, drainage, sclerotherapy, and ablation. With the growing complexity of procedures and expanding clinical indications, bleeding complications have emerged as a critical concern, potentially compromising treatment outcomes and posing life-threatening risks in severe cases. However, no systematic international consensus exists on the prevention and management of these complications. This international expert consensus statement was developed by a multidisciplinary panel of 51 specialists from six countries. The development process followed the World Health Organization Handbook for Guideline Development, was reported in accordance with the Reporting Items for Practice Guidelines in Healthcare statement, and was appraised using the Appraisal of Guidelines for Research and Evaluation II instrument. Evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach, and recommendations were refined through a two-round modified Delphi process. A total of 20 recommendations were finalized, covering classification, risk assessment, periprocedural prevention, post-procedural monitoring, and stepwise management of bleeding complications. A dual classification based on time of onset and severity is proposed to support standardized clinical communication and decision-making. Multidimensional pre-procedural risk assessment incorporates procedural risk, patient-related factors, lesion characteristics, device-related factors, and operator experience. The recommendations also address individualized periprocedural management, risk-adapted post-procedural ultrasound surveillance, and stepwise hemostatic management ranging from local compression and tract embolization to selected ultrasound-guided interventions, transarterial embolization, and surgery. These recommendations provide a practical framework for clinical decision-making across a broad range of interventional ultrasound procedures while allowing individualized application according to procedural characteristics, patient-related risk factors, operator experience, and institutional resources. The available evidence remains heterogeneous across procedures, and some recommendations are partly dependent on expert opinion where high-quality direct evidence is limited. This consensus statement provides a standardized, evidence-based framework to guide clinical practice, improve patient safety, and optimize procedural outcomes in interventional ultrasound. Further multicenter prospective studies are needed to validate and refine these recommendations.