Angiography-Assisted Cone-Beam CT–Guided Radiofrequency Ablation for Hepatocellular Carcinoma: Single-Center Workflow and Early Outcomes

Background: Conventional CT- or US-guided radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) often limits repeat contrast-enhanced imaging and provides suboptimal intraprocedural conspicuity, which can hinder precise targeting and margin assessment. Purpose: To describe a single-center angiography-assisted cone-beam CT (angio-CBCT) RFA workflow and report early outcomes versus an institutional conventional CT–guided cohort. Materials and Methods: In this IRB-approved single-center retrospective study, consecutive patients underwent angio-CBCT–guided RFA for HCC (n=14). Selective intra-arterial injections (≈20–40 mL iodinated contrast per CBCT) through a 5-Fr catheter permitted multiple intraprocedural CBCT acquisitions for targeting, verification, and endpoint assessment under general anesthesia. Primary outcomes were technical success, early local recurrence, and complications (CTCAE v6.0). For a secondary imaging analysis, within-patient change in lesion conspicuity (ΔHU = HU_tumor − HU_liver) from preprocedural contrast-enhanced CT to intraprocedural imaging was compared in available cases (angio-CBCT n=12; conventional CT n=13). Descriptive statistics were used. Results: Angio-CBCT RFA achieved technical success in 14/14 (100%) procedures; early local recurrence was 0/14 (0.0%); and one complication occurred (1/14, 7.1%; Grade 3). Intraprocedural refinements included immediate re-ablation in 3/14 (21.4%) and electrode repositioning in 2/14 (14.3%), with on-table detection of an additional lesion in 1/14 (7.1%). In the institutional conventional cohort, technical success was 19/20 (95.0%), early local recurrence 2/20 (10.0%), and complications 0/20 (0%). Lesion conspicuity improved with angio-CBCT (median ΔHU 290.1 HU, n=12) but not with conventional CT (−10.5 HU, n=13). Conclusion: Angio-CBCT–guided RFA for HCC is feasible and safe and enables repeatable, low-volume contrast–enhanced intraprocedural imaging that supports precise targeting, verification, and timely refinements. Early outcomes and markedly improved lesion conspicuity suggest potential advantages over conventional CT–guided workflows and warrant prospective validation in larger cohorts.