pdf

Absolute and relative contraindications of radiofrequency
ablation of focal liver tumors
Poster No.:
C-552
Congress:
ECR 2009
Type:
Educational Exhibit
Topic:
Interventional Radiology
Authors:
F. Vandenbroucke , J. de Mey ; Brussels/BE, Jette/BE
DOI:
10.1594/ecr2009/C-552
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Learning objectives
To outline the relative and absolute contraindications of image-guided percutaneous
radiofrequency ablation (RFA) of the liver.
To describe the major and fatal complications after a series of 146 RFA procedures and
to look for possible risk factors in the literature.
Background
RFA is being increasingly used in the treatment of focal liver tumours. The indications
for this procedure on the basis of tumour size and number are well established. In this
exhibit we propose a list of contraindications which, in the setting of RFA, can lead to
major complications and even death.
Between March 1999 and September 2008, a total of 156 RFA procedures of the liver
were performed in our department. Two patients died within one month after RFA. A
further two patients suffered major complications: a liver abscess and peritoneal bleeding
respectively.
We analyzed the patients' records and looked for risk factors that could have attributed
to these events. Also, we studied the literature to propose a list of relative and absolute
contraindications.
Imaging findings OR Procedure details
A wide variety of exclusion criteria and contraindications circulate in the literature,
however a list of relative and absolute contraindications supported by peer reviewed
literature include:
1/ COAGULATION STATUS (Prothrombin activity < 50%, Prothrombin time ratio >50%,
Platelet count < 50 X 109 /L, INR >1.4, Recent use of anticoagulants)
•
•
•
As with any percutaneous procedure, RFA should be postponed until
correction of diathesis to avoid bleeding (1)
RFA is life threatening if coagulopathy is overlooked (2-7)
Since needles of 17-14 Gauge are used, the amount of needle repositioning
should be minimized and the needle tract should always be cauterized
Page 2 of 19
•
Fig.: Subcapsular haematoma (white arrow) after percutaneous RFA of a
subcapsular lesion (open arrow). RFA of a second lesion (black arrow) was
performed subsequently without change in the subcapsular haematoma.
Follow up CT scan should be performed if the patient complains of pain or if
there is a drop in haemoglobin
2/ LOCALIZATION OF THE TUMOUR
A/ Adjacent to hollow viscera:
stomach / colon / small bowel
•
•
•
•
Risk of perforation due to burning of the wall of the adjacent intestine
Perforation has been identified as one of the most serious lethal
complications of RFA of the liver (2,5,7-10)
The colon is more at risk because it is fixed to the abdominal wall
The stomach, thanks to its thicker wall, and the more mobile small bowel are
less at risk
Page 3 of 19
•
•
•
Fig.: A) PET CT scan of a small metabolically active lesion (arrow) in
segment 2 of the liver in a patient with a total of three hepatic lesions.
B) RFA electrode at the level of the lesion. C) coronal reformat CE CT
scan performed the next day shows the ablation zone and thickening of
the adjacent gastric wall (arrow). After 14 days the patient presented at
the emergency department with painless heamatemesis and melena. D)
Gastroscopy revealed a big necrotic ulcer (arrow) in the bulbus duodeni
(Forrest Ib). After conservative treatment follow up gastroscopy 2 months
later could not reveal any residual lesion.
Care should be taken for subcapsular lesions < 1cm from the intestine
Techniques to prevent bowel injury during RFA: water instillation (11,12) or
balloon catheter interposition (13)
Early detection of perforation is essential to survival
B/ Hilar tumours/ Neighbouring big bile ducts
•
•
Fatal outcomes and major complications due to stenosis of central bile ducts
(2,14)
Protection of vascular structures by heat sink effect
Page 4 of 19
•
•
Fig.: A) Metastasis of a CRC in segment VIII of the liver adjacent to the
right hepatic venous branch (open arrow). B) Follow up CE CT scan shows
complete ablation of the lesion. The vessels (arrow) run through the ablation
zone. This patient has been tumour free for over 3 years.
Strictures develop slowly
Peripheral bile duct strictures are often asymptomatic
Page 5 of 19
•
Fig.: Bile duct dilatation (arrow) distal from an ablated lesion located in the
center of segment IV. Shown here is treatment failure at the posterior side of
the lesion (open arrow).
Bilioma formation after damage to bile ducts
Page 6 of 19
Fig.: A) CE CT scan and PET CT show a small metastasis of a colorectal
carcinoma in the liver (arrow). B) RFA of this lesion with a switching control
needle. C) Follow up CT after a second RFA session shows the ablation
zone (arrow). Another new metastasis appeared in the left liver lobe (open
arrow). D) CE CT scan and PET CT 4 months after the third RFA session
(open arrow) show the formation of a bilioma (arrow). No clinical symptoms
were noted.
Page 7 of 19
C/ Gallbladder
•
•
Cholecystitis can develop after RFA of a lesion close to the gallbladder
(7,9,15,16)
Perforation is rare due to the fluid content within the gallbladder
disseminating the heat (3)
D/ Subcapsular position
•
•
•
Believed to be associated with a higher risk of complications
Needle should always traverse normal liver tissue to prevent bleeding
High risk for tumour seeding (17) has not been confirmed by other studies
(18)
E/ Neighbouring the heart
•
•
Cardiac complications of RFA include dysrhythmias, vasovagal reaction, and
infarction (14,19,20)
No direct thermal damage to the heart muscle has been reported
F/ Subphrenic lesion
•
Technically more difficult, careful needle positioning by skilled operator
required
Page 8 of 19
Page 9 of 19
•
•
Fig.: A) T1 weighted image after Gadolinium administration shows a small
HCC (arrow) in a subdiaphragmatic position. B) CT fluoroscopy image of the
RFA. C) Follow up MRIshows complete ablation of the lesion.
More frequently complicated by: pneumothorax, pleural effusions,
haemothorax, injury of the diaphragm (with shoulder pain), paralysis of the
diaphragm (5-7,21)
Mostly self limiting
3/ IMPAIRED LIVER FUNCTION
•
•
Fatal outcome after RFA due to liver failure (3,4,9,21,22)
Care should be taken in cirrhotic patients, especially Child-Pugh C
Page 10 of 19
Page 11 of 19
Fig.: A,B) CE CT scans and MRI T1 weighted images in arterial phase
show two hypervascular nodules (arrows) in a Child B(9) cirrhotic patient
with elevated alpha fetoprotein and diabetes mellitus. The nodule on the
right side was a biopsy confirmed HCC. C) Two days after RFA we saw an
ablation zone around the lesions (arrows). Ascites was present. This patient
died 10 days after the ablation as a result of liver failure.
4/ INFECTION
· Abscess formations are well documented complications of RFA of the liver (2-6,21,24)
Fig.: A) Hepatic abscess formation in the right liver lobe after RFA. The patient
complained of a prolonged fever. CT scan shows 2 gas containing lesions. B) The
patient's condition improved after percutaneous drainage of the abscess with a pig tail
catheter.
· Nearly all abscesses resolve after percutaneous drainage
· Septic shock, peritonitis and multiple organ failure leading to death have been reported
(2,21)
· Diabetes and biliary enteric communication / presence of biliary air are risk factors
Page 12 of 19
Fig.: A) CT scan of a metastasis of a small cell lung carcinoma (arrow) adjacent to
a biliary tract filled with gas. The patient had no previous abdominal interventions. B)
RFA of the lesion. C) One day after the ablation CE CT scan showed a big ablation
zone with signs of an infarction anteriorly (open arrow). This patient died 5 days later
from septic shock and multiple organ failure.
· Prophylactic use of antibiotics is controversial
5/ Portal vein thrombosis
•
•
Theoretical risk: hepatic infarct and insufficiency
However can be considered as safe as the procedure under Pringle
manoeuvre (25)
6/ Implanted defibrillators, pacemakers
•
•
•
Possible risk of radiofrequency wave interference with the function of the
device
Malfunction has been observed in a minority (26,27)
Advisable to inactivate the implantable cardioverter defibrillator during the
procedure (5)
7/ PROTHESTHESIS, SCARS, INADEQUATE GROUNDING PADS
To avoid burn wounds, care should be taken with:
•
Inadequately sized (28) or imperfections with the grounding pads
Page 13 of 19
Page 14 of 19
•
•
Fig.: Burns on both legs (grade 1 on the right, grade 3 on the left) as a
result of damaged grounding pads, probably due to oxidation. The expiration
date was not yet reached. Grounding pads should always be checked for
colour changes (arrows) before applying them to the patient.
Any interface (eg scars) between skin and pads (3)
Grounding pads should not be applied within the neighbourhood of a
metallic prosthesis (2)
* Situations in which RFA is not indicated - as it would be an ineffective treatment - are not
considered real contraindications, such as:
- Size and number of lesions
- Extrahepatic spread
- Location adjacent to a big portal or hepatic vein
- Life expectancy < 3 or 6 months
Images for this section:
Page 15 of 19
Fig. 1: Subcapsular haematoma (white arrow) after percutaneous RFA of a subcapsular
lesion (open arrow). RFA of a second lesion (black arrow) was performed subsequently
without change in the subcapsular haematoma.
Page 16 of 19
Conclusion
A thorough preliminary examination of the history and previous images of candidates for
RFA leads to better patient selection, and will minimize the risk of complications in future
procedures. It could identify the patients in which other therapeutic options should be
considered.
Risk of complications should be weighted as a risk versus benefit ratio for each patient.
Meticulous preevaluation of candidates should exclude patients with
1.
2.
3.
4.
uncorrected coagulopathy
insufficient underlying hepatic reserve
pneumobilia (colonized biliary tract)
tumours adjacent to non displaceable critical structures
Personal Information
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