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

<b>Background:</b> 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. <b>Purpose:</b> 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. <b>Materials and Methods:</b> 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. <b>Results:</b> 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). <b>Conclusions:</b> 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.