Venous Thromboembolism and Bleeding in Endonasal Skull Base Surgery: A Systematic Review and Meta‐analysis

OBJECTIVE: To quantify venous thromboembolism (VTE), deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications after endonasal skull base surgery, and to explore variability across studies and surgical approaches. DATA SOURCES: Medline, Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL). REVIEW METHODS: Four reviewers searched five databases for English-language cohort or case-control studies of anterior skull base surgery. Studies were excluded for noneligible comparisons, interventions, populations, or incomplete complication reporting. RESULTS: The search identified 1360 studies. After removing duplicates, 925 titles/abstracts were screened, with 765 excluded. One hundred sixty full-text articles were assessed, and 108 studies (25,462 patients) were included. Pooled random-effects incidence of VTE was 1.4% (95% CI 1.1%-1.7%; prediction interval [PI] 0.3%-6.2%). Individual rates were 1.0% for DVT (95% CI 0.8%-1.2%; PI 0.4%-2.8%) and 1.1% for PE (95% CI 0.8%-1.3%; PI 0.3%-3.6%). Overall bleeding occurred in 2.2% (95% CI 1.8%-2.7%; PI 0.5%-9.5%). VTE rates were highest in Cushing's disease (3.8%, 95% CI 3.0%-4.8%) and malignancy (4.5%, 95% CI 2.9%-7.1%). Expanded approaches generally showed higher complication rates than standard approaches (VTE 3.1% vs 1.5%, bleeding 4.3% vs 2.0%). CONCLUSION: Endonasal skull base surgery is associated with low rates of VTE and bleeding, but between-study heterogeneity is considerable, and event rates may exceed average reported rates in some settings, supporting individualized prophylaxis, particularly for higher-risk pathologies and when using expanded approaches.