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

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.

Medline, Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL).

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.

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%).

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.