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BackTable / VI / Topic / Procedure
Liver Ablation
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Pre-Procedure Prep
Modalities
• Radiofrequency ablation
• Microwave ablation
• Cryoablation - less common for liver
• Irreversible electroporation (IRE): non-thermal ablation
Operator preference
Some prefer microwave because:
• Faster
• Larger ablation volume
• Less susceptible to heat sink
• Multiple probes have synergistic effect
• Microwave ablation travels through all tissues: charred tissue
• Tissue contraction which can work to your advantage
Indications
• HCC - potentially curative for lesions <3 cm. Potential to downstage tumor to fall within Milan criteria
• Unresectable hepatic metastases
• Curative vs. Palliative intent
Ideal patient:
• Size less than 3 cm
• Safe distance from vasculature and vital structures (central bile ducts)
Non-ideal patients:
• Consider other therapy
• Within 2 cm of liver hilum
• Lesions in close proximity to bowel that cannot be effectively hydrodissected
Contraindications
• Life expectancy <6 months
• Child-Pugh class C
• ECOG 3 or 4
• Active infection
• Bile duct or major vessel invasion
• Uncorrectable coagulopathy
• No safe approach
Pre-Operative Evaluation
• H&P
• Labs: coagulation, LFTs
• Prior imaging - CT and/or MRI
Consider involving anesthesia early
• Anesthesia with paralytics can be helpful for breath hold maneuvers
Liver Ablation Podcasts
Listen to leading physicians discuss liver ablation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Episode #378
In this episode, Dr. Constantinos (Costi) Sofocleous, Dr. Bruno Odisio, and Dr. William Rilling discuss the history of percutaneous liver tumor ablation, takeaways from past and present clinical studies, and the contemporary role of ablation margin confirmation software for optimizing treatment outcomes.
Episode #377
In this episode, host Dr. Chris Beck interviews Dr. Juan Gimenez and Dr. Tyler Sandow. Juan and Tyler are both interventional radiologists in New Orleans, Louisiana who practice at Ochsner Health System - one of the United States’ leading transplant centers. As a result, both doctors have significant experience in Y-90 radiation segmentectomy and other complex procedures for treatment of hepatocellular carcinoma (HCC).
Episode #257
In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures.
Procedure Steps
Antibiotic Prophylaxis
• Recommended, especially for high-risk patients (biliary-enteric anastomosis, cirrhosis, diabetes)
• For low risk patients: 1-2 g cefazolin (Ancef) IV
• Multiple regimens for high risk patients: 1.5 g ampicillin/sulbactam (Unasyn) IV is simplest
• Vancomycin or clindamycin for Gram-positive coverage (PCN allergy) and gentamicin for Gram-negative coverage
Margins Are Key
• Circumferential: Example: 2 cm met needs 4 cm ablation zone
• 10 mm for metastatic lesions
• 5 mm for HCC
Can use US, CT, angiography with cone beam CT or combination of modalities
Percutaneous Approach
• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
Mark skin site and prep large area
Insert probes
• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes
Protective techniques if needed
• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage
Ablate
• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal
Following ablation, helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary
• Will depend on tumor location, orientation, vital structures and size
• Largest ablation zone will be along long axis of probe. Can use to operator advantage by orienting probe along long axis of the tumor
• Target temperature: 60° for microwave
• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
• Mark skin site and prep large area
Insert Probes
• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes
Protective Techniques if Needed
• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage
Ablate
• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal
Following Ablation
• Helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary
Liver Ablation Articles
Read our exclusive BackTable VI Articles for quick insights on liver ablation, provided by physicians for physicians.
Post-Procedure
Complications
• Hemorrhage
• Vascular complications: portal vein thrombosis, hepatic venous thrombosis, infarct, AV fistula and pseudoaneurysm
• Pain
• Abscess formation/Infection
• Biloma or bile leak
• Post-ablation syndrome - fever, fatigue, nausea, myalgia 7-10 days following procedure. Occurs 30-60% of patients.
• Extrahepatic complications: depends on location. Examples: diaphragm injury, bowel injury
Post-Operative Care
• Many patients can be discharged same day
• Monitor patient for at least 2 hours for development of pain, signs of bleeding, or extrahepatic injury
• Schedule follow up clinic visit and imaging.
• For liver tumor follow up CT or MRI in 1-2 months.
• Helpful to maintain consistency with pre and post imaging. MR often preferred over CT
• Follow tumor markers and LFTs
Liver Ablation Demos
Watch video walkthroughs of liver ablation on the BackTable VI expanded content network.
Liver Ablation Tools
Check out liver ablation apps, calculators, and decision aids to assist you in your day to day practice.
References
[1] Glassberg MB, Ghosh S, Clymer JW, Wright GWJ, Ferko N, Amaral JF. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):98. Published 2019 Jun 10. doi:10.1186/s12957-019-1632-6
[2] Vogl TJ, Nour-Eldin NA, Hammerstingl RM, Panahi B, Naguib NNN. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Mikrowellenablation (MWA): Grundlagen, Technik und Ergebnisse in primären und sekundären Lebertumoren – Übersichtsarbeit. Rofo. 2017;189(11):1055‐1066. doi:10.1055/s-0043-117410
[3] Hinshaw JL, Lubner MG, Ziemlewicz TJ, Lee FT Jr, Brace CL. Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation--what should you use and why?. Radiographics. 2014;34(5):1344‐1362. doi:10.1148/rg.345140054
[4] Yu H, Burke CT. Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors. Semin Intervent Radiol. 2014;31(2):129‐137. doi:10.1055/s-0034-1373788
[5] Kim KR, Thomas S. Complications of image-guided thermal ablation of liver and kidney neoplasms. Semin Intervent Radiol. 2014;31(2):138‐148. doi:10.1055/s-0034-1373789
[6] Lubner MG, Brace CL, Ziemlewicz TJ, Hinshaw JL, Lee FT Jr. Microwave ablation of hepatic malignancy. Semin Intervent Radiol. 2013;30(1):56‐66. doi:10.1055/s-0033-1333654
[7] Groeschl RT, Wong RK, Quebbeman EJ, et al. Recurrence after microwave ablation of liver malignancies: a single institution experience. HPB (Oxford). 2013;15(5):365‐371. doi:10.1111/j.1477-2574.2012.00585.x
Disclaimer: The Materials available on https://www.BackTable.com/ are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
The NeuWave Microwave Ablation System: A Quick Start Guide for IRs
Evolving Practices: Microwave Ablation with Multiple Probes & Ablation Confirmation Software
Ready, Aim, Ablate: Optimizing the Liver Ablation Zone
Contributors
Dr. Driss Raissi