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Introduction The Subdural Evacuating Port System (SEPS; Medtronic, Galway, Ireland) is a widely utilized minimally invasive approach to the management of chronic subdural hematomas (cSDH), particularly in the elderly and medically complex patients. However, SEPS based management remains limited by rates of hematoma recurrence and acute treatment failure. Middle meningeal artery embolization (MMAE) has emerged as an adjunctive strategy that has been shown to decrease recurrence following surgical evacuation of cSDH. We performed a systematic review to compare outcomes of SEPS alone and SEPS combined with MMAE for the treatment of cSDH.Methods A systematic review was performed to identify studies evaluating treatment of cSDH using SEPS alone or in combination with MMAE. Searches were conducted in PubMed, Scopus, and Embase. Extracted variables included demographic information, pre-morbid use of anticoagulants or antiplatelet agents, and procedural characteristics, including embolic material in MMAE cases. The primary outcome was recurrence requiring operative intervention. Secondary outcomes included acute treatment failure (requirement for a second operative procedure during index hospitalization) and hospital length of stay. Outcomes were compared between SEPS alone and SEPS combined with MMAE (SEPS+MMAE) cohorts.Results Eighteen studies met inclusion criteria, including 12 studies evaluating SEPS alone, 5 evaluating SEPS+MMAE, and 1 study reporting data from both cohorts. The SEPS alone population consisted of 1,053 patients with 1,137 hematomas and the SEPS+MMAE cohort included 310 patients with 390 hematomas. Patient demographics were similar between groups. Mean ages were 71.7 in the SEPS alone cohort and 76.1 years in the SEPS+MMAE cohort and female patients comprised 30.9% and 34.2% of each cohort, respectively. The use of anticoagulants and/or antiplatelet agents was more common in the SEPS+MMAE cohort (61.6% vs. 38.8%, p<0.0001). Among SEPS+MMAE studies, particulate embolics and/or coils were used in 66.1% of cases and liquid embolics in 33.9%.In studies reporting rates of operative recurrence, SEPS alone (9 studies, 813 hematomas) demonstrated a recurrence rate of 12.1% compared to 5.1% in the SEPS+MMAE cohort (6 studies, 390 hematomas) (p<0.001, OR: 2.54). Acute treatment failure occurred in 13.7% of SEPS alone cases (11 studies, 1058 hematomas) and 8.4% of SEPS+MMAE cases (3 studies, 311 hematomas) (p=.016, OR 1.74). Length of stay was shorter in the SEPS+MMAE cohort (weighted mean 6.39 days) compared with SEPS alone (weighted mean 8.54 days), though comparisons were descriptive due to inconsistent reporting of variance across studies.Conclusion This systematic review demonstrates that the addition of MMAE to SEPS based treatment of cSDH is associated with a significant reduction in recurrence requiring reoperation. Acute treatment failure remains a clinically relevant limitation of SEPS treatment, with only modest differences observed between groups. Together, these findings support a complementary role for MMAE in enhancing the durability of minimally invasive approaches without eliminating their intrinsic limitations.Disclosures K. Vinn: None.