Economic analysis of n-butyl cyanoacrylate compared with ethylene vinyl alcohol copolymer liquid embolic embolization of brain arteriovenous malformations (bAVMs) from a US hospital perspective

Abstract

Background: In US hospitals, the liquid embolic systems (LESs) n-butyl cyanoacrylate (n-BCA) and ethylene vinyl alcohol copolymer (EVOH) are used for brain arteriovenous malformation (bAVM) embolization to achieve presurgical devascularization. The aim of this study was to perform an economic analysis comparing four techniques for bAVM embolization based on LES, ancillary device, and angiography suite time costs.

Methods: An economic model was developed comparing the embolization costs for n-BCA, EVOH with the plug and push technique, EVOH with detachable-tip microcatheters, and EVOH with balloon microcatheters. Per procedure costs were calculated for bAVMs with one to four pedicles. Annual cohort analyses were performed to evaluate the potential impact for low and high-volume centers. Sensitivity analyses were performed to determine cost drivers.

Results: The analyses showed that the n-BCA technique was the least costly of the four techniques. Total per procedure costs for one to four embolized pedicles ranged from $5941 to $10,074 for the n-BCA technique, $8428 to $30,345 for the EVOH balloon microcatheter technique, $12,711 to $47,477 for the EVOH plug and push technique, and $13,900 to $52,233 for the EVOH detachable-tip microcatheter technique. Cohort analyses costs for 52 annual cases ranged from $308,953 to $523,838 with the n-BCA technique and from $722,816 to $2,716,096 with the EVOH detachable-tip microcatheter technique.

Conclusions: Procedure costs associated with n-BCA are lower than those with each of the three EVOH techniques examined. Future cost analyses should compare the costs of new LES products once available.

Keywords: Intracranial arteriovenous malformations; Onyx 18; Onyx 34; cost analysis; n-butyl-cyanoacrylate.

Figure 1.

Example radiographs of the EVOH and n-BCA techniques. (a-b) n-BCA Technique: (a) Embolization was performed using n-BCA for the SCA AVM. (b) Post embolization complete obliteration cerebellar AVM (no residual shunting). (c-d) EVOH Plug and Push Technique: Embolization was performed using Onyx™ 34 as the plug and Onyx™ 18 for the push. (c) Right frontal AVM (2.0 × 1.7 × 1.5 cm); anterior MCA – superficial drainage frontal/temporal cortical veins in the superior sagittal sinus and right sphenoparietal sinus. (d) Post embolization complete obliteration AVM (no residual shunting). Abbreviations: AVM: arteriovenous malformations; MCA: middle cerebral artery; SCA: superior cerebral artery. Source: Dr. Sudhakar R. Satti, Neurointerventional Surgery, Christiana Care Health System.

Figure 2.

Cost per procedure for the four embolization techniques. Per procedure costs for LES, microcatheters, and angiography suite time for each of the four treatments analyzed for the embolization of bAVMs with one pedicle. Abbreviations: EVOH: ethylene vinyl alcohol copolymer; LES: liquid embolic system n-BCA: n-butyl cyanoacrylate.