Rates and Risk Factors for 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 1,360 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 1.35% (95% CI 1.07–1.71%; prediction interval 0.28–6.20%). Component rates were 0.99% for DVT (95% CI 0.79–1.24%; PI 0.35–2.79%) and 1.06% for PE (95% CI 0.84–1.33%; PI 0.30–3.63%). Overall bleeding occurred in 2.16% (95% CI 1.76–2.66%; PI 0.47–9.47%). VTE rates were highest in Cushing’s disease (3.80%, 95% CI 3.01–4.79%) and malignancy (4.54%, 95% CI 2.86–7.13%). Expanded approaches generally showed higher complication rates than standard approaches, consistent with greater case complexity. Conclusion: Endonasal skull base surgery is associated with low mean rates of VTE and bleeding, but between-study heterogeneity is considerable. Prediction intervals indicate that event rates may exceed pooled means in some settings, supporting individualized prophylaxis, particularly for higher-risk pathologies and when using expanded approaches. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany