Middle meningeal artery embolization for chronic subdural hematoma using PVA 45-150 particles versus n-BCA glue: a pragmatic study with analysis of estimated cost.

INTRODUCTION

Middle meningeal artery (MMA) embolization has increasingly been utilized as a standalone treatment or adjunct to surgical evacuation for chronic subdural hematoma (cSDH). Superiority in cost or effectiveness between polyvinyl alcohol (PVA) particles and n-butyl cyanoacrylate (n-BCA) glue, two common embolic agents, has not been definitively demonstrated.

METHODS

A retrospective review of consecutive MMA embolizations performed between January 2022 to December 2024 at a single institution was completed. All procedures were performed by one of the two senior authors and embolic agent preference was determined by the performing neuroendovascular surgeon; this allowed for a practical, real-world comparison of techniques within a shared patient population, at a single institution with consistent management strategies. Demographics, cSDH characteristics, adjunctive treatments, anesthesia/procedure time, fluoroscopy time/dose, procedural complications, and modified Rankin Score (mRS) were noted. Procedure-specific cost of MMA embolization was estimated by summing microcatheter and embolic material prices (available from manufacturers or online wholesalers) and adding estimated IR suite operational cost per minute from the literature multiplied by anesthesia time.

RESULTS

139 patients underwent 185 MMA embolizations (46 bilateral). 76 patients (54.7 %) were treated with PVA 45-150 and 63 (45.3 %) with 17 %-20 % n-BCA. 61.9 % were male, with an average age of 71.2 ± 11.6 years. 55.4 % of procedures were via femoral access. There was no significant difference in mean cSDH width preoperatively (p = 0.35), at 24 h post-intervention (p = 0.71), or last follow up CT (p = 0.57). Pre-procedure (p = 0.24) and final follow up mRS (p = 0.22) were similar. The overall rate of recurrent SDH within 60 days of the index procedure was 6.52 % and complication rate was 0.72 %, with no significant differences between groups. 47.4 % of patients underwent an operative adjunct (craniotomy, subdural evacuating port system (SEPS), or burr holes) with similar rate of adjunct use in each group (p = 0.12). Fluoroscopy time (p = 0.01), anesthesia time (p < 0.001), and procedure time (p = 0.01) were lower in the PVA group, but fluoroscopy dose was not significantly different between groups (0.70). There was a statistically significant difference in average estimated procedure-specific cost between groups (PVA: 9794.20 [8691.50, 11913.80] USD, n-BCA: 17562.50 [15034.50, 21376.50] USD, p < 0.001)

CONCLUSIONS

Over the two-year study period, there was no difference in clinical outcomes for MMA embolization using PVA versus n-BCA. The average estimated procedure-specific cost of PVA particles was significantly lower than that of n-BCA glue.