Comparison of distal and transradial approaches for endovascular procedures on the forearm radial artery (a systematic review and meta-analysis)

The distal radial access (DRA) in the anatomical snuffbox area is considered as a modification of the transradial access (TRA), potentially reducing the incidence of radial artery occlusion (RAO) and local complications, while preserving the proximal radial artery (RA) segment for future interventions.

Aim: To evaluate the efficacy and safety of DRA compared with conventional TRA for endovascular procedures based on current randomized clinical trials (RCTs) and meta-analyses (2022–2026), with a focused quantitative synthesis of randomized evidence and a narrative overview of other procedural setting.

Methods. PubMed/MEDLINE, Web of Science Core Collection, Google Scholar, and eLIBRARY (including manual search of reference lists) were searched using PRISMA 2020 from January 1, 2022, to February 1, 2026. Only meta-analyses and prospective RCTs were included; Retrospective studies, case-control designs, and clinical cases were excluded. The primary outcome was RAO (by assessment time), secondary outcomes were technical access success, access change (crossover), local complications, hemostasis time, operator radiation exposure, and ergonomics. A sensitivity analysis was performed at ≤ 48 hours (at discharge) and 30–90 days.

Results. Nine RCTs (only coronary procedures) were included in the quantitative synthesis of RAO. In the subgroup of comparable timing (48 hours / 30 days / 60 days / 1 month / 3 months; k = 6), DRA reduced the risk of LA: RR = 0.37 (95% CI 0.25–0.54), I² = 0%. A risk reduction was also found for RAO at 24 hours (k = 1). 12-month data are presented in the TENDERA RCT. Sensitivity analysis stratified by the time of RAO assessment showed consistent results.

Conclusions. According to RCTs and meta-analyses, DRA is associated with a reduction in RAO and several local complication/ hemostasis benefits in 2022–2026. However, it often requires crossover and longer cannulation times during the development phase. The “protective effect” of DRA on the radial artery remains stable over different observation periods. Practical implications: DRA is appropriate for patients where preserving the proximal radial artery is important (repeated interventions, potential bypass/fistula), provided experience and patent hemostasis and/or ultrasound-guided protocols are available.

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