Incidence and risk factors of complications following microsecond and nanosecond pulsed electric field ablation for hepatocellular carcinoma: a 10-year multicenter cohort study.

OBJECTIVES: To evaluate the incidence and risk factors of complications following percutaneous pulsed electric field (PEF) ablation for hepatocellular carcinoma (HCC) in high-risk anatomical locations based on a 10-year multicenter experience. MATERIALS AND METHODS: This retrospective multicenter study enrolled patients with HCC who underwent microsecond PEF (μsPEF) or nanosecond PEF (nsPEF) ablation across seven medical centers between July 2015 and July 2025. Complications were categorized into minor or major according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) modified classification system. Propensity score matching (PSM) was employed to compare the safety profiles between the μsPEF and nsPEF cohorts, and exploratory oncologic outcomes were assessed in patients with available follow-up data. RESULTS: A total of 304 patients (mean age, 58.0 ± 11.0 years; 241 males) with 338 tumors were included. The overall complication rate was 7.6% (23/304), and the major complication rate was 3.3% (10/304). Major complications primarily comprised perioperative systemic events, thoracic injuries in subphrenic tumors, and needle tract complications. Post-ablation syndrome (PAS) occurred in 18.8% of patients. Lower platelet count was identified as a significant risk factor for major complications (p = 0.007). After PSM, no significant differences were observed in major complication rates between the μsPEF and nsPEF cohorts (1.9% vs. 4.7%, p = 0.450). CONCLUSIONS: Percutaneous PEF ablation demonstrates a favorable safety profile for HCC in high-risk anatomical locations. Both μsPEF and nsPEF exhibit similar safety profiles. Although rare, major complications necessitate vigilant perioperative care and needle tract surveillance. KEY POINTS: Question The safety profile and complication patterns of pulsed electric field ablation for hepatocellular carcinoma remain insufficiently characterized in large-scale multicenter cohorts. Findings In this 10-year multicenter study, major complications occurred in 3.3% of patients, with no significant differences observed between microsecond and nanosecond pulsed electric field cohorts. Clinical relevance Pulsed electric field ablation is a safe option for hepatocellular carcinoma in high-risk locations, though vigilant perioperative care and needle tract surveillance remain essential.