Direct oral anticoagulants are effective in preventing but not resolving radial artery occlusion: a systematic review and meta-analysis of randomized controlled trials

Objective This systematic review, including a meta-analysis, aimed to investigate the efficacy and safety of direct oral anticoagulants (DOACs) in preventing and resolving radial artery occlusion (RAO) following transradial artery access. Methods We synthesized evidence from randomized controlled trials (RCTs) identified in PubMed, CENTRAL, Scopus, and Web of Science up to May 2025. Using Stata MP v. 17, we employed a fixed-effects model to report dichotomous outcomes, presenting relative risk ratio (RR) with a 95% confidence interval (CI). Trial sequential analysis (TSA) was conducted to investigate the robustness and reliability of the cumulative evidence. Results Four RCTs with 970 participants were included. DOACs significantly decreased the incidence of RAO [RR: 0.49, 95% (0.31, 0.79), p < 0.001]. However, in terms of RAO resolution, there were no differences between groups [RR: 1.22, 95% CI (0.80, 1.88), p = 0.36]. Moreover, there were no differences between groups regarding the incidence of hematoma [RR: 0.56, 95% (0.12, 2.61), p = 0.46], minor bleeding [RR: 1.55, 95% (0.72, 3.32), p = 0.26], and major bleeding [RR: 2.41, 95% (0.48, 12.25), p = 0.36]. There were no incidences of arteriovenous fistula, pseudoaneurysm, or compartment syndrome throughout the trials. Conclusion DOACs significantly prevented the incidence of RAO, although TSA indicates that this finding is not yet conclusive. No significant differences were found between groups regarding RAO resolution or the incidence of hematoma, minor bleeding, or major bleeding. Systematic Review Registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251063999.