Thermal-assisted visceral pleural dissection to overcome pleural tenting during lung ablation: A technical innovation

Percutaneous thermal ablation of subpleural and fissural lung lesions can be technically challenging because the visceral pleura may tent rather than allow smooth probe penetration. This can limit accurate probe positioning and delay or complicate lesion access. We describe a simple operator-initiated technique that uses brief, controlled thermal activation of the ablation probe to facilitate traversal of the visceral pleural interface during lung ablation procedures. Four patients with metastatic lung lesions undergoing CT-guided percutaneous thermal ablation demonstrated significant pleural tenting during probe advancement. Procedures were performed under general anesthesia with controlled breath-hold technique. In one case, microwave energy was applied for a short interval through the ablation probe to assist pleural penetration, while in three cases cryoablation probes were briefly activated using the active thaw (“i-Thaw”) function to achieve pleural dissection. In all cases, immediate CT imaging confirmed successful disruption of the tented pleura and allowed advancement of the probe into the target lesion. No pneumothorax, pleural complications, or bronchial fistula were identified on intraprocedural or immediate postprocedural imaging. This preliminary experience suggests that short, controlled thermal activation of ablation probes may provide a practical adjunctive technique for overcoming visceral pleural tenting during lung ablation procedures and improving access to difficult subpleural lesions. Further study is needed to better define procedural safety, reproducibility, and optimal energy settings.