Transradial Versus Transfemoral Access in Percutaneous Coronary Intervention for Chronic Coronary Syndromes: A GRADE-Assessed Systematic Review and Meta-Analysis

The choice of vascular access in percutaneous coronary intervention (PCI) significantly influences procedural safety and patient outcomes. While the transradial approach (TRA) is established as superior in acute coronary syndromes, its efficacy and safety in chronic coronary syndromes (CCS) undergoing elective PCI remain less clearly defined. This meta-analysis aimed to compare the TRA versus the transfemoral approach exclusively in patients with CCS. A systematic search of PubMed, Embase, and Cochrane Library was conducted from inception to September 2025, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Randomized controlled trials and observational studies comparing the TRA and transfemoral approach in CCS were included. Primary outcomes were 30-day mortality, major adverse cardiovascular events, and major bleeding. Secondary outcomes included myocardial infarction, stroke, blood transfusion, procedural success, hospital stay, and access-site surgery. Data were pooled using a random-effects model, and certainty of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluations framework. Seven studies met the inclusion criteria. TRA significantly reduced major bleeding risk (risk ratio, 0.41; P < 0.0001) and the need for blood transfusion (risk ratio, 0.36; P = 0.0003). No significant differences were observed in 30-day mortality (P = 0.84), major adverse cardiovascular events (P = 0.25), myocardial infarction (P = 0.40), stroke (P = 0.13), or procedural success (P = 0.30). Heterogeneity was low for most outcomes. In patients with CCS undergoing elective PCI, the TRA significantly reduces bleeding and transfusion risk without compromising procedural success or major cardiovascular outcomes. These findings reinforce TRA as the preferred access site even in stable, low-risk populations, supporting its broader adoption in contemporary practice.