Predictors of crossover from transradial to transfemoral access in coronary angiography and intervention: insights from 9081 consecutive procedures

Background The transradial approach (TRA) for coronary angiography (CAG) and percutaneous coronary intervention (PCI) offers reduced bleeding, earlier mobilization, and improved comfort compared with the transfemoral approach (TFA). Anatomical and technical challenges may necessitate crossover to TFA, prolonging procedures and increasing complications. Objectives To identify patient, lesion, and procedural predictors of TRA-to-TFA crossover in an all-comers cohort. Methods This retrospective single-center study included all TRA CAG or PCI procedures between September 2020 and April 2023, excluding distal TRA, cardiogenic shock, mechanical support, prior radial harvest, or dialysis fistula indication. Demographic, clinical, and angiographic variables were compared between crossover and noncrossover patients. Independent predictors were identified by logistic regression. Results Among 9081 TRA patients, 836 (9.2%) required crossover to TFA. Independent predictors included female sex [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.75–2.39], operator experience <2 years (OR 2.05, 95% CI 1.44–2.16), radial/brachial artery spasm (OR 1.37, 95% CI 0.78–1.59), lack of support (OR 1.24, 95% CI 0.94–1.62), PCI of circumflex-obtuse marginal (OM) territory (OR 4.76, 95% CI 1.68–8.33), bifurcation lesions (OR 2.54, 95% CI 1.23–5.25), moderate/severe calcification (OR 2.01, 95% CI 1.49–3.17), long lesions (OR 2.75, 95% CI 1.69–4.03), severely angulated lesions (OR 2.33, 95% CI 0.87–3.72), and chronic total occlusions (OR 2.86, 95% CI 1.21–5.29). Conclusion Although TRA offers multiple advantages, specific patient, lesion, and procedural factors significantly increase crossover risk. Recognizing these predictors preprocedurally may optimize access strategy, reducing procedure time, radiation exposure, and complications.