Episode # 640 • 01 May 2026
Hepatic Arteriography & C-Arm CT-Guided Liver Ablation
When a liver tumor is hard to see, the limits of conventional image guidance can become the limits of treatment. In this episode of the BackTable Podcast, Netherlands interventional oncologist Dr. Maarten (M.L.J.) Smits shares a step-by-step walkthrough of the new hepatic arteriography and C-arm CT–guided ablation (HepACAGA) technique, punctuated with a real-world case series at the end. Find out how intra-arterial contrast, cone-beam CT, and 3D needle guidance can improve tumor conspicuity, targeting accuracy, and ablation margin assessment within a single angiography suite.
Timestamps
00:00 - Introduction
02:55 - Netherlands Tech Access
04:31 - Origin of HepACAGA
07:14 - Why Use a Catheter?
11:24 - Tools and Setup
13:13 - Catheters and Devices
17:06 - Contrast Protocol Basics
22:51 - Targeting and Needle Guidance
31:09 - Patient Selection
35:56 - Extra Benefits and Multimodal
39:58 - Workflow and Outcomes
46:14 - Evidence and Early Studies
51:41 - Rethinking Size Cutoffs
57:54 - HCC Case Walkthrough
01:02:27 - Hard-to-See Metastasis
01:06:22 - Margin Driven Reablation
01:11:04 - Bleeding and Embolization
01:16:05 - Renal ACAGA Expansion
01:23:31 - Adoption and Next Steps
Resources
You may also like
More about this episode
Dr. Smits explains the origins of HepACAGA and why catheter-based contrast delivery can meaningfully change ablation planning, particularly for small lesions, poorly visualized tumors, and cases where ultrasound or conventional CT guidance may be insufficient. He walks through the practical setup, including catheter positioning, contrast dilution, timing protocols, needle navigation, apnea/end-expiration technique, and built-in fusion for immediate ablation verification. He also describes how the angio suite environment supports multimodal treatment, including intraprocedural embolization when bleeding occurs or when additional transarterial therapy is needed.
The episode also examines early outcomes from Dr. Smits’ group, including a reported reduction in local recurrence from approximately 25% to 5%, with a modest increase in procedure time. Case examples include HCC, small colorectal liver metastases, margin-driven re-ablation, hemorrhage management, and extension of the ACAGA concept to renal tumors (RenACAGA).
The Materials available on BackTable are provided for informational and educational purposes only and are not a substitute for the independent professional judgment of a qualified healthcare professional in diagnosing or treating patients. Any opinions, statements, or views expressed are those of the individual contributors and do not necessarily reflect those of the publisher, platform, or any affiliated organization.