Transradial Versus Transfemoral Access for Mechanical Thrombectomy in Acute Ischemic Stroke: An Update Meta-Analysis and Trial Sequential Analysis

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BACKGROUND AND OBJECTIVE: Transfemoral access (TFA) is the standard for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Transradial access (TRA) is a feasible alternative. Despite advances, no recent systematic review or meta-analysis exists, highlighting the need for updated evidence. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases were searched up to February 2024 for articles comparing TRA with TFA for MT in AIS. Studies were included if they reported at least one outcome, with at least 10 patients per group. Random-effects models were applied, with odds ratios (ORs) used for dichotomous outcomes and mean differences (MDs) for continuous outcomes. RESULTS: Our analysis included 763 TRA patients and 3527 TFA patients, with one randomized study and nine observational studies. We found no significant differences in successful recanalization (OR 0.88, 95% CI: 0.59-1.32), complete recanalization (OR 1.15, 95% CI: 0.92-1.43), first pass effect (OR 0.83, 95% CI: 0.68-1.01), puncture-to-recanalization time (MD -1.67, 95% CI: -7.48 to 4.13), access site complications (OR 0.70, 95% CI: 0.28-1.76), symptomatic intracranial hemorrhage (OR 0.93, 95% CI: 0.62-1.39), crossover (OR 1.71, 95% CI: 0.75-3.92), number of passes (MD 0.17, 95% CI: -0.08-0.41), length of hospitalization (MD -0.59, 95% CI: -1.28-0.09), and favorable outcomes at 3 months (OR 0.85, 95% CI: 0.58-1.23). Trial sequential analysis showed that successful recanalization, puncture-to-recanalization time, and first pass effect did not reach the required information size, indicating inconclusive results, whereas access complications analysis suggested a high probability of similarity between the two treatments. CONCLUSION: TRA is a viable alternative to TFA for MT in AIS, with comparable safety and efficacy. Although current evidence does not support widespread adoption, the introduction of radial-specific devices and advancements in operator training could improve outcomes. Further randomized trials with larger sample sizes are needed to clarify TRA's role and optimize neurointerventional practices compared with TFA.

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