Objective: Tumor location is a critical factor for determining technical success and local recurrence following percutaneous ablation of hepatocellular carcinomas (HCC). The purpose of this retrospective study was to evaluate the safety and outcome measures of percutaneous microwave ablation (pMWA) for HCCs < 4 cm in difficult locations. Methods: Retrospective review included 81 patients who underwent pMWA for HCCs < 4 cm. Fourty-three patients (30 males and 13 females; mean age, 61 years) with 53 HCCs located near the diaphragm, heart, gallbladder, kidney, gastrointestinal tract, large vessel and exophytic location were included under difficult location group. Thirty-eight patients (29 males and nine females; mean age, 60 years) with 48 HCCs in other locations were included under control group. Baseline demographics were recorded. Technical efficacy, local tumor progression (LTP) and complication rates were evaluated. Results: Mean follow up period was 3.4 months (range 1–7). There was no major complication in both the groups; two patients had a mild perihepatic hemorrhage in the difficult location group which was managed conservatively. There was no difference between the groups in the overall technical efficacy rate (84.9% vs 91.7%, p = 0.294), LTP rate (4.4% vs 2.2%. p = 0.57) or complication rate (4.6% vs 0%, p = 0.177). Conclusion: Our data suggest that there is no significant difference in technical efficacy, LTP or complication rates for MWA in both difficult and normal locations. Advances in knowledge: With proper patient selection, pre-procedural planning and appropriate technique, pMWA is feasible, safe and effective for small HCCs in difficult location with an acceptable range of complications.

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A complication of transjugular and direct intrahepatic portosystemic stent (TIPS and DIPS) graft is stent blockage. Routinely described procedures for shunt revision include angioplasty, deployment of endoprosthesis, catheter-directed thrombolysis, or rarely performing a second parallel TIPS/DIPS. We describe a case of hepatic vein outflow tract obstruction who presented with DIPS blockage. We performed a revision where a new stent was placed by a lateral puncture through the fenestration of the existing dysfunctioning DIPS stent graft. In our opinion, this alternate technique has theoretical advantages over the conventionally described parallel TIPS/DIPS as it prevents the creation of a completely new long hepatic parenchymal tract.

Purpose To compare the safety and efficacy of radiofrequency ablation (RFA) versus microwave ablation (MWA) for hepatocellular carcinomas (HCC) smaller than 5 cm in critical locations. Methods Single-center retrospective study of all patients who underwent RFA/MWA for HCC from July 2015 to Dec 2019. Critical location includes exophytic tumors, tumors ≤ 5 mm from the diaphragm, heart, gallbladder, kidney, gastrointestinal tract, and ≤ 10 mm from large vessels with caliber of ≥ 3 mm. Treatment effectiveness, local tumor progression, and complication rates were evaluated. Results Out of 119 patients with 147 HCC nodules in critical location, 65 (M:F = 49:16; mean age–61.7) were included in RFA group and 54 (M:F =43:11; mean age–60.5) in MWA group. Mean follow-up period was 16.5 and 14.8 months, respectively. At first follow-up imaging, 66/78 tumors in RFA group and 57/69 tumors in MWA group showed complete ablation with primary treatment effectiveness rates of 84.6% and 82.6%, respectively (p = 0.741). Local tumor progression (LTP) rate was 21.8% (17/78) and 20.3% (14/69), respectively (p = 0.826). Median time to LTP was 12 and 13.5 months, respectively. Fourteen tumors in RFA group and 12 in MWA group underwent reablation with a secondary treatment effectiveness rates of 78.6% (14/17) and 83.3% (12/14), respectively (p = 0.757). Mean LTP-free survival was 37.2 and 28.1 months, respectively. The total complication rate was 36.9% and 31.5%, respectively (p = 0.535) with no major complications in both the groups. Conclusion Our data suggest that both MWA and RFA are equally safe and effective for treating HCCs < 5 cm in critical locations.