AJR 2003; 181:495-497
© American Roentgen Ray Society
Life-Threatening Hypertensive Crises in Two Patients Undergoing Hepatic Radiofrequency Ablation
Gary Onik1,
Casey Onik1,
Irene Medary1,
Debra M. Berridge2,
Debra S. Chicks2,
Lester T. Proctor3,
Thomas C. Winter, III2 and
Fred T. Lee, Jr.2
1 Celebration Health, Ste. A-280, 400 Celebration Pl., Celebration, FL
34747.
2 Department of Radiology, University of Wisconsin, E3/311 Clinical Science
Center, 600 Highland Ave., Madison, WI 53792.
3 Department of Anesthesiology, University of Wisconsin, Madison, WI
53792.
Received October 15, 2002;
accepted after revision January 8, 2003.
Address correspondence to F. T. Lee, Jr.
(ftlee{at}wisc.edu).
Introduction
Radiofrequency ablation has proved to be a relatively safe and effective
treatment for use in the destruction of hepatic tumors
[1,
2]. Among the considerations in
planning radiofrequency ablation are the adjacent structures that might be
injured by the radiofrequency thermal lesion. Examples of complications
related to proximity of major structures include bowel perforation,
cholecystitis, bile duct stricture, and portal vein thrombosis
[3–5].
Lesions in the posterior aspect of the right lobe of the liver can be adjacent
to the right adrenal gland, which raises the possibility of adrenal injury
during radiofrequency ablation. In this article, we describe two hypertensive
crises caused by heating of the adrenal gland during radiofrequency ablation
of posterior right lobe hepatic tumors.
Case Report 1
A 79-year-old man with no history of hypertension presented with metastatic
colon carcinoma to the liver. Three lesions were noted preoperatively, the
largest being approximately 6 cm in diameter in the right lobe of the liver
adjacent to the right adrenal gland.
At open laparotomy, two lesions were resected and a cholecystectomy was
performed. The lesion in segment VII was considered unresectable because of
the patient's age, a close association with the right hepatic vein, and a
margin of less than 1.0 cm from the inferior vena cava as seen on
intraoperative sonography and CT (Fig.
1A,
1B,
1C,
1D). Under sonographic
guidance, a three-pronged radiofrequency probe (Cool-tip cluster, Radionics,
Burlington, MA) was placed in the lesion. The first radiofrequency probe
placement was in the most inferior aspect of the lesion. On application of
radiofrequency energy, the patient's blood pressure increased from 130 over 80
mm Hg to 250 over 170 mm Hg in less than 1 min. The radiofrequency ablation
was halted and the patient was immediately treated with two 10-mg doses of IV
labetalol hydrochloride (Normodyne, Schering-Plough, Kenilworth, NJ) for
approximately 5 min, after which his blood pressure returned to baseline. The
remainder of the lesion was then ablated with multiple overlapping ablations
without further incident. We suspected that the hypertensive crisis could have
been due to heating of the adrenal gland, which resulted in the release of
catecholamines. This suspicion prompted testing of the patient's
intraoperative catecholamine levels. Test results confirmed a massive increase
in catecholamine levels. Dopamine was 62,920 pg/mL (normal, 0–20 pg/mL),
epinephrine was 22,240 pg/mL (normal, 10–200 pg/mL), and norepinephrine
was 4440 pg/mL (normal, 80–520 pg/mL). Postoperatively, the patient's
catecholamine levels returned to normal and he remained normotensive
thereafter, with no sequelae.
View larger version (179K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —79-year-old man with metastatic colon cancer. Contrast-enhanced CT
scan obtained before radiofrequency ablation shows large metastasis from colon
cancer in posterior segment of right lobe of liver.
|
|
View larger version (180K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —79-year-old man with metastatic colon cancer. Contrast-enhanced CT
scan obtained before radiofrequency ablation shows inferior aspect of tumor
(long arrow) lying adjacent to right adrenal gland (short
arrow).
|
|
View larger version (170K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —79-year-old man with metastatic colon cancer. Contrast-enhanced CT
scan obtained after radiofrequency ablation shows lesion extending to capsule
of liver and adjacent to right adrenal gland.
|
|
View larger version (161K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —79-year-old man with metastatic colon cancer. Contrast-enhanced CT
scan obtained after radiofrequency ablation. More inferiorly in liver,
radiofrequency lesion extends to liver capsule adjacent to right adrenal
gland, which now appears swollen with indistinct margins (arrow).
|
|
Case Report 2
A second, similar case of radiofrequency-induced hypertension occurred
shortly thereafter. A 63-year-old woman with no history of hypertension was
referred for percutaneous radiofrequency ablation of a 3.0-cm hepatic
metastatic lesion in the liver from a colorectal primary cancer. The tumor was
located in segment VIII, adjacent to the inferior vena cava, with the caudal
aspect of the tumor immediately above the right adrenal gland (Fig.
2A,
2B,
2C).
View larger version (173K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —63-year-old woman with metastatic colon cancer. Contrast-enhanced CT
scan of abdomen obtained before radiofrequency ablation shows tumor to be
posterior to inferior vena cava and just cephalad to right adrenal gland.
|
|
View larger version (173K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —63-year-old woman with metastatic colon cancer. Contrast-enhanced CT
scan of abdomen obtained immediately after radiofrequency ablation shows close
proximity of radiofrequency probe tip (arrow) to right adrenal gland
(arrowhead).
|
|
View larger version (177K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —63-year-old woman with metastatic colon cancer. Contrast-enhanced CT
scan of abdomen obtained after radiofrequency ablation at level approximately
1.0 cm below B shows adrenal gland (arrowhead) as edematous
because of thermal injury. Note gas bubbles (arrow) caused by tissue
boiling adjacent to posterior aspect of adrenal gland.
|
|
Because of our experience with the other patient, we alerted the anesthesia
team to the possibility of catecholamine release and hypertensive crisis.
Before starting the ablation, we placed an arterial line for continuous blood
pressure monitoring. The patient was then taken to the CT suite and
administered a general anesthetic. Within approximately 1 min after the
radiofrequency procedure started, the patient's blood pressure rose sharply
from a baseline of 130 over 62 mm Hg to 208 over 114 mm Hg. The ablation was
immediately stopped and the patient was treated with one 4.0-mg dose of IV
hydralazine hydrochloride (Apresoline, Novartis, Basel, Switzerland). Her
blood pressure rapidly returned to baseline. A short-acting ß-blocker,
esmolol hydrochloride (Brevibloc, Baxter, Deerfield, IL), was immediately
available if evidence of cardiac arrhythmia was seen, but it was not
required.
Discussion
The purpose of this article is to describe a potentially life-threatening
complication associated with radiofrequency ablation of liver tumors.
Hypertensive crisis is defined as a sudden increase in systolic and diastolic
blood pressure associated with potential end-organ damage of the central
nervous system, the heart, or the kidneys
[6]. The causes of hypertensive
crisis are varied, although the cause in the patients described here is
analogous to stimulation of the adrenals during surgery for pheochromocytoma
[7]. In this patient
population, life-threatening hypertensive crisis and cardiac irritability are
precipitated by massive catecholamine release during manipulation of the tumor
for surgical removal. The severe hypertension in our patients was also
probably caused by a massive catecholamine release, presumably due to heating
of the adjacent adrenal gland.
Experience with radiofrequency ablation of adrenal tumors is limited but
has been reported in select cases of metastatic adrenal cortical carcinoma. To
our knowledge, hypertension was not a prominent feature in the only clinical
series reported to date [8].
The most likely explanation for the lack of massive catecholamine release in
these cases is the replacement of normal adrenal tissue by nonfunctioning or
poorly functioning tumor. However, if a portion of the normal remaining
adrenal gland is heated during the ablation, or the tumor is
endocrinologically active, patients will very likely be at risk for
hypertensive crisis. Whether the potential of hypertensive crisis is a
contraindication for adrenal radiofrequency ablation remains a clinical
decision to be made case by case.
Two main classes of drugs are used for the treatment of hypertensive crisis
caused by catecholamine excess: ß-blockers and peripheral vasodilators.
Alpha-adrenergic blockade has been considered the mainstay of therapy for
pheochromocytoma, but sole reliance on 
-blockers can precipitate or
aggravate tachycardia and arrhythmias. In the first case presented in this
report, labetalol hydrochloride was used in isolation. Labetalol hydrochloride
is a combined blocker of - and ß-adrenergic receptors. The ratio
of - to ß-blockers is 1:7 when they are given IV. In patients
undergoing hypertensive crisis due to catecholamine excess, the ready
availability of a ß-blocker to prevent cardiac arrhythmia is essential.
Unlike pure ß-blockers, which decrease cardiac output, labetalol
hydrochloride maintains cardiac output while its -blocking
characteristic reduces peripheral vascular resistance, maintaining cerebral,
renal, and coronary blood flow. Controversy arises in that some authors
believe the relatively lower -blocking characteristics of labetalol
hydrochloride in the periphery may not overcome the opposing ß-blocking
action on the heart, causing a paradoxical increase in blood pressure and
acute cardiac decompensation
[6].
The second patient was successfully treated with a vasodilator (hydralazine
hydrochloride); ß-blocker (esmolol hydrochloride) was on standby for
treatment of cardiac arrhythmias. Simultaneous use of a ß-blocker and
another -blocking agent, such as phentolamine, could be considered an
alternative treatment in this setting. Phentolamine accompanied by esmolol
would have the same benefit of providing both - and ß-blockade
while allowing easier titration of blood pressure. In radiofrequency ablation
of right lobe liver tumors, as opposed to resection of pheochromocytomas,
long-acting adrenergic blocking agents such as phenoxybenzamine and
propranolol may outlast the catecholamine output from the adrenal gland and
cause postprocedural hypotension.
Lesions in the posterior aspect of the right lobe of the liver are
particularly amenable to percutaneous radiofrequency ablation because they are
not adjacent to the bowel. However, the close proximity of the right adrenal
gland and the associated risk of hypertension should be considered in these
cases. At a minimum, careful patient monitoring and premedication or
intraoperative antihypertension treatment should be considered. An open
laparotomy or a laparoscopic approach with isolation of the adrenal gland from
the thermal lesion may also help prevent acute hypertension.
In conclusion, tumors near the adrenal gland that are treated with
radiofrequency may create a life-threatening hypertensive crisis. To prevent a
catastrophic result, the possibility of this complication should be
anticipated and brought to the attention of the anesthesiologist before the
procedure. We believe that careful patient preparation, close physiologic
monitoring, and communication with the anesthesiologist should be an integral
part of cases of this nature.
References
- Curley S, Izzo F, Delrio P, et al. Radiofrequency ablation of
unresectable primary and metastatic hepatic malignancies. Ann
Surg 1999;230:1
–8[Medline]
- Curley S, Izzo F, Ellis L, Vauthey N, Paolo V. Radiofrequency
ablation of hepatocellular cancer in 110 patients with cirrhosis.
Ann Surg 2000;232
: 381–391[Medline]
- Solbiati L, Oerace T, Tonolini M, Osti V, Cova L. Radiofrequency
thermal ablation of hepatic metastases. Eur J
Ultrasound 2001;13:149
–158[Medline]
- Goldberg SN. Radiofrequency tumor ablation: principles and
techniques. Eur J Ultrasound 2001;13
: 129–147[Medline]
- Llovet J, Vilana R, Bru C, et al. Increased risk of tumor seeding
after percutaneous radiofrequency ablation for single hepatocellular
carcinoma. Hepatology2001; 33:1124
–1129[Medline]
- Varon J, Maric P. The diagnosis and management of hypertensive
crisis. Chest2000; 118:423
–427
- Manger WM, Gifford RW. Pheochromocytoma. J Clin
Hypertens 2002;4:62
–72
- Abraham J, Fojo T, Wood BJ. Radiofrequency ablation of metastatic
lesions in adrenocortical cancer. (letter) Ann Intern
Med 2000;133:312
–313[Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
E. N. Chini, M. J. Brown, M. A. Farrell, and J. W. Charboneau
Hypertensive Crisis in a Patient Undergoing Percutaneous Radiofrequency Ablation of an Adrenal Mass Under General Anesthesia
Anesth. Analg.,
December 1, 2004;
99(6):
1867 - 1869.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. W. Mayo-Smith and D. E. Dupuy
Adrenal Neoplasms: CT-guided Radiofrequency Ablation--Preliminary Results
Radiology,
April 1, 2004;
231(1):
225 - 230.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Report 1
