Quality Initiatives: Strategies for Anticipating and Reducing Complications and Treatment Failures in Hepatic Radiofrequency Ablation

Abstract

Radiofrequency (RF) ablation is one of several local treatment strategies that can be used for the destruction of a variety of primary and secondary liver tumors. As experience with RF ablation grows, it becomes increasingly evident that successful ablation requires meticulous technique. In addition, knowledge of potential complications is critical for both the interventionalist and the radiologist, whose postablation interpretation can facilitate identification of complications and treatment failures. Hepatic RF ablation offers significant advantages in that it is less invasive than surgery and carries a low risk of major complications. Successful prevention of complications and treatment failures begins at initial consultation and continues with preablation evaluation of specific patient factors such as coagulation profiles, use of medications, and risk factors for infection. Other predisposing factors include background liver cirrhosis, prior hepatectomy, and portal hypertension. During ablation, careful attention must be given to tumor size, number, and location. For large or multiple ablations, separate ablation sessions can help reduce the prevalence of postablation syndrome, and clustered electrodes and multiple overlapping treatment zones may be used to reduce the risk of treatment failure. It is critical to reevaluate tumors during ablation to determine the best approach and to compensate for changes in size and relative location due to patient positioning. With use of these strategies, hepatic RF ablation can be performed with greater safety, better patient tolerance, and a reduced risk of complications and treatment failures.

Complications of radiofrequency ablation of hepatic tumors: Frequency and risk factors

“…Similar results were reported by Curley et al [9] (0.9% in 608 patients) and Livraghi et al [6] (0.5% in 2320 patients). It is believed to be a result of direct trauma from needle positioning rather than thermal injury (due to the protective "heat-sink" effect) [14,15] . Injuries to small vessels not visible on ultrasonography (US) are usually responsible for its origin.…”

“…Both of them tend to have a benign course and stop spontaneously. Venous bleeding is usually treated conservatively or with blood transfusions only; arterial bleeding is more severe and may require surgical or endovascular intervention [9,14,16] . Tract cauterization by the withdrawal of the needle in high temperatures may prevent this kind of complication and should be performed in all cases [12] .…”

“…Rhim, in one of his articles, states that the open or the laparoscopic approach can decrease this kind of complication since needle positioning and withdrawal is under direct vision [16] . Transcatheter arterial embolization is the treatment of choice for this hemorrhagic complication [9,14,17] . Several authors have also described hemothorax [8,12,15] .…”

“…They also found that tumors in liver segment I was a significant risk factor for this type of bleeding. Avoiding puncturing dilated biliary radicles should prevent such complications to occur [14] . Subcapsular hematoma and abdominal wall hematoma have also been described.…”

“…Patients who have undergone previous hepatectomy are also at risk for this complication [14] . Its incidence ranges from 0.2% to 4.3% [4,9,11,12] .…”