Direct percutaneous puncture versus transarterial embolization for head and neck paragangliomas: A systematic review and meta-analysis

Introduction Embolization of head and neck paragangliomas (HNPs) is a well-established treatment strategy and adjunctive therapy. However, the optimal mode of intervention, whether by direct percutaneous puncture (DP) or via transarterial embolization (TAE), remains unclear. Methods The aim of this study was to complete a systematic literature review and meta-analysis to compare the safety and efficacy of DP versus TAE for HNP embolization. The Cochrane Library and MEDLINE databases were used to identify studies describing the clinical outcomes of either DP or TAE for HNP embolization. Outcome measures included: complete angiographic devascularization, major complications, and minor complications. Pooled rates were calculated for each variable which were then compared with meta-regression using a random effects model. Results Thirty-one retrospective studies met inclusion criteria, detailing 394 patients with 411 HNPs. Overall, DP was associated with a higher rate of complete devascularization (91.5%, 95% confidence interval [CI]: 85.6% to 97.4%; I-2 = 0%) when compared to TAE technique (40.1%, CI: 27.2% to 58.9%; I-2 = 93%). However, there was no difference regarding major complication rates between DP (6%, CI:1.3% to 10.8%; I-2 = 0%) and TAE for HNP embolization (3.3%, CI: 1.4% to 5.3%; I-2 = 0%) (p = 0.370), nor in minor complications between the techniques (p = 0.211). Subgroup analysis of TAE embolic agents revealed that particle embolics were associated with a significantly lower rate of major complications (2.5%; 0.4% to 4.6%; I-2 = 0%) when compared to liquid embolics (10.6%, CI:4% to 17.3%; I-2 = 48%; p = 0.022). Conclusions A DP approach for HNP embolization results in a higher rate of complete devascularization and with a similar complication profile when compared to TAE. These findings also suggest that particle embolics are associated with fewer major complications compared to liquid embolics when TAE is utilized.