Comparing Transradial and Transfemoral Access in Acute Ischemic Stroke Treatment

Alongside the traditional transfemoral access (TFA) route in mechanical thrombectomy (MT) for the treatment of acute ischemic stroke (AIS), transradial access (TRA) is emerging as an alternative with potential advantages, such as reduced puncture site complications and shorter recovery time. However, concerns remain regarding smaller vessel diameter, tortuosity, and risk of vasospasm. This systematic review aims to compare TRA versus TFA in MT across procedural and clinical outcomes for the treatment of AIS patients. A systematic literature search was performed in Nested Knowledge via PubMed, OVID, Springer and Cochrane databases until July 2025. Articles were included if they compared both access routes (TFA and TRA). Clinical outcomes of interest were good functional outcomes defined as modified Rankin Scale (mRS) 0‐2 and safety outcomes included total access site complications, with a sub‐analysis of arterial vasospasms and hematoma at the puncture site. Procedural outcomes included rates of first pass recanalization (FPR), successful (eTICI≥2b67) and complete recanalization (eTICI 3), number of passes required to achieve recanalization, and recovery time. Continuous outcomes were converted to standardized mean or median values, weighted by sample size, and compared between radial and femoral arms. Comparisons between TRA and TFA groups were made through a Welch's two‐sided T‐test for means and a Mann‐Whitney U‐test for medians, assuming no equal variance, using R‐studio. 343 articles were screened and 16 studies (1 RCT, 15 retrospective observational) were included representing 1288 TRA and 5019 TFA patients. Good functional outcomes were similar between TRA and TFA (38% vs 40.1%, p=0.38) and remained similar in mean mRS scores (3.31 vs 2.99, p=0.17). Access site complications were lower in the TRA group (3.46% vs 7.62%, p=0.01). However, no differences were observed in arterial vasospasms between TRA and TFA (3.07% vs 0%, p=0.12), nor for hematoma or bleeding at the puncture site (1.95% vs 3.06%, p=0.17). FPR was similar between the two groups (52% vs 49.3%, p=0.96) along with the mean number of passes to achieve recanalization (1.8 vs 1.76, p=0.74). Successful recanalization (87.6% vs 88.9%, p=0.69) and complete recanalization (49.3% vs 46.5%, p=0.8) were also similar in both approaches. Recanalization outcomes were consistent with the findings from the singular RCT. The mean time to recanalization was significantly shorter in the TRA group (41.9 vs 48.6 min, p<0.0001), as well as the total procedural time (50.2 vs 60 min, p<0.0001). The in‐hospital recovery time trended lower for TRA but without statistical significance (6.99 vs 9.15 days, p=0.08). The TRA approach for MT in AIS patients is comparable to the conventional TFA route in terms of procedural and clinical outcomes. Notably, TRA is associated with a significantly lower rate of access site complications and shorter procedural and recanalization times, without increased risk of vasospasm or hematoma. These findings support TRA as a safe and effective alternative to TFA in appropriate patients, potentially enhancing patient comfort and reducing complication rates. Further prospective and randomized studies are warranted to further validate these benefits and clarify patient selection criteria.