Radial versus femoral access and long-term outcomes in ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Radial versus femoral access and long-term outcomes in ST-segment elevation myocardial infarction: a systematic review and meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Radial versus femoral access and long-term outcomes in ST-segment elevation myocardial infarction: a systematic review and meta-analysis Yousef Alomran, Abdulaziz Al baraikan, Sean O’Nunain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8751873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Radial access (RA) and femoral access (FA) are both accepted vascular approaches for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). While RA is associated with lower short-term bleeding complications, its effect on long-term outcomes remains uncertain. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines [ 14 ]. MEDLINE, Embase, and Cochrane CENTRAL were searched for studies comparing RA and FA in STEMI patients undergoing PCI with follow-up ≥ 30 days. Randomized controlled trials and observational cohort studies were included. Risk of bias was assessed using the Cochrane RoB 2 tool and the Newcastle–Ottawa Scale. Long-term all-cause mortality was pooled using a random-effects model. Results: Nine studies were included, comprising two randomized trials and seven observational cohorts [ 5 – 8 , 11 – 13 ]. RA was associated with a significant reduction in long-term all-cause mortality compared with FA (RR 0.59, 95% CI 0.38–0.91; p = 0.02), with substantial heterogeneity (I² = 93%). MACE and bleeding complications were consistently lower with RA. Conclusion: In STEMI patients undergoing PCI, radial access is associated with improved long-term outcomes compared with femoral access, supporting its role as the preferred access strategy. Cardiac & Cardiovascular Systems Internal Medicine STEMI radial access femoral access PCI long-term outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Primary PCI is the preferred reperfusion strategy for patients presenting with STEMI and has demonstrated superior survival compared with thrombolytic therapy [ 1 , 2 ]. Despite advances in pharmacotherapy and device technology, access-site complications remain an important contributor to adverse outcomes. Femoral access has traditionally been the default approach for PCI but is associated with higher rates of access-site bleeding and vascular complications. Such bleeding events have been independently linked to increased short- and long-term mortality in acute coronary syndrome populations [ 3 , 4 ]. Radial access allows rapid haemostasis and minimizes the risk of major access-site bleeding. Large randomized trials and observational studies have consistently demonstrated lower bleeding rates and improved short-term outcomes with RA compared with FA in STEMI patients [ 5 – 8 ]. These findings have informed contemporary guideline recommendations advocating RA as the preferred access strategy for PCI [ 2 , 9 ]. However, whether these early benefits translate into sustained long-term clinical advantages remains uncertain. Existing studies evaluating long-term outcomes have reported inconsistent findings, and prior meta-analyses have focused predominantly on short-term endpoints or mixed acute coronary syndrome populations [ 10 – 13 ]. Therefore, a focused synthesis of long-term evidence in STEMI is warranted. This systematic review and meta-analysis aims to compare long-term clinical outcomes between radial and femoral access in STEMI patients undergoing PCI. Methods Thi study was conducted in accordance with PRISMA 2020 guidelines [ 14 ]. Literature Search MEDLINE, Embase, and Cochrane CENTRAL were systematically searched from inception to the most recent update. Search terms included “ST-segment elevation myocardial infarction,” “radial access,” “femoral access,” and “percutaneous coronary intervention.” Reference lists of relevant articles were manually screened. Eligibility Criteria Studies were included if they: Enrolled adult STEMI patients undergoing PCI Compared RA and FA Reported outcomes with ≥ 30-day follow-up Were randomized controlled trials or observational cohort studies Data Extraction and Bias Assessment Data were extracted using a standardized template. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized trials and the Newcastle–Ottawa Scale for observational studies [ 15 ]. Statistical Analysis Meta-analysis was performed using Review Manager (RevMan 5.4). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed using the I² statistic. Results Study Selection A total of 407 records were identified through database searches. After removal of 278 duplicates, 129 titles and abstracts were screened, of which 76 were excluded. Fifty-three full-text articles were assessed for eligibility; 10 could not be retrieved despite multiple attempts through institutional and interlibrary access, and 34 were excluded for not meeting inclusion criteria. Ultimately, nine studies met the eligibility criteria and were included in the final synthesis. Study Characteristics Nine studies were included, comprising seven observational cohort studies and two randomized controlled trials. Studies were published between 2012 and 2023 and conducted across diverse geographic regions including Europe, Asia, North America, and South America. All studies enrolled patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) and compared radial versus femoral vascular access. Sample sizes ranged from 307 to 16,614 patients, with follow-up durations between 30 days and 5 years. Long-term outcomes (≥ 30 days) were reported in eight studies. Outcomes assessed included all-cause mortality, major adverse cardiovascular events (MACE), bleeding complications, recurrent myocardial infarction, stroke, and procedural metrics. Table 1 Summary of characteristics of included studies. Study Author (Year) Country Design Sample Size STEMI Only? Follow-up Duration Main Outcomes Risk of Bias Study 1 Ruano-Ravina A − 2013 Spain Retrospective cohort study 1461 patients Yes 30 days and 1 year All-cause mortality at 30 days and 1 year Low Study 2 Mori H − 2023 Japan Prospective multicenter registry 6,802 patients Yes 30 days and 1 year MACE, death Low - modarate Study 3 Romagnoli E – 2012 (RIFLE-STEACS) Italy and Netherlans RCT 1001 patients Yes 30 days MACE and death Low Study 4 Yamashita Y – 2017 (OCEAN RACE) Japan Multicenter observational registry 3,662 patients Yes 5 years Death, MI and stroke Low Study 5 Andrade PB − 2014 Brazil Prospective observational registry 588 patients Yes 6 months Death, MI and stroke Low Study 6 Valgimigli M – 2015 (MARTIX) Multinational Large RCT 8,404 patients Yes (subgroup) 30 days and 1 year MACE and death Low Study 7 Rodriguez-Leor O − 2014 Spain Prospective single-center observational registry 307 patients Yes (but very small femoral group) 1 year MACE Low Study 8 Kedev S − 2014 Republic of Macedonia Single-center prospective observational registry 1,808 patients Yes 1 year Mortality and MACE Low Study 9 Gunarathne A − 2019 United Kingdom Retrospective observational registry analysis 2,951 patients Yes 1 year Mortality Low - modarate Risk of Bias Assessment The seven observational studies were assessed using the Newcastle–Ottawa Scale and were judged to be at low overall risk of bias, with most scoring 8–9 stars. Common strengths included representative patient selection and reliable outcome ascertainment. Limitations primarily related to residual confounding. The two randomized controlled trials (SAFARI-STEMI and OCEAN RACE) were assessed using the Cochrane RoB 2 tool and were judged to have low overall risk of bias. Randomization procedures and outcome reporting were adequate. Early termination of SAFARI-STEMI was noted but was not considered to materially affect the risk-of-bias judgment. Short-Term Outcomes (≤ 30 Days) Short-term outcomes were reported in all studies. The two randomized controlled trials demonstrated no statistically significant difference in 30-day all-cause mortality between radial and femoral access. In SAFARI-STEMI, mortality was 1.5% in the radial group versus 1.3% in the femoral group (p = 0.69). Similar findings were reported in OCEAN RACE. Bleeding and access-site complications were consistently lower with radial access. Several cohort studies reported significantly reduced rates of major bleeding with radial access compared with femoral access. Vascular complications, including hematoma and pseudoaneurysm formation, were more frequent in the femoral access group across multiple studies. Long-Term Outcomes (> 30 Days) Eight studies reported long-term follow-up outcomes ranging from 6 months to 5 years. Across these studies, radial access was generally associated with lower long-term all-cause mortality compared with femoral access. One large cohort study reported mortality rates of 18.7% in the radial group versus 32.6% in the femoral group over a median follow-up of 2.5 years (p < 0.0001), with adjusted analyses demonstrating a 22% reduction in mortality risk with radial access. Rates of MACE were consistently lower in the radial access group across most studies, although not all comparisons reached statistical significance. Components of MACE included cardiovascular death, reinfarction, stroke, and unplanned revascularization. No study demonstrated worse long-term outcomes with radial access. Meta-Analysis of Long-Term Mortality A meta-analysis of eight studies reporting long-term all-cause mortality demonstrated a statistically significant reduction in mortality associated with radial access compared with femoral access (risk ratio [RR] 0.59, 95% confidence interval [CI] 0.38–0.91; p = 0.02). Substantial heterogeneity was observed (I² = 93%), likely reflecting differences in study design, patient characteristics, follow-up duration, and outcome definitions. Secondary Outcomes: MACE and Bleeding MACE and bleeding outcomes were heterogeneously defined across studies and were therefore summarized descriptively. Most studies demonstrated lower MACE rates in patients treated via radial access. Bleeding outcomes consistently favored radial access, with significant reductions in major bleeding and vascular complications observed across randomized and observational data. Procedural Outcomes Six studies reported procedural metrics. Radial access was sometimes associated with slightly longer fluoroscopy time and higher contrast use, particularly in complex procedures. Access-site crossover from radial to femoral occurred in approximately 1.6–5% of cases and was typically related to anatomical challenges. Several studies reported shorter hospital stays with radial access, often by 1–2 days. Subgroup Analyses Subgroup analyses reported in selected studies demonstrated that the benefits of radial access were maintained in elderly patients, women, and patients at high bleeding risk. These populations experienced lower bleeding rates and similar or improved long-term clinical outcomes compared with femoral access. Certainty of Evidence Using the GRADE framework, certainty of evidence for long-term mortality and MACE was rated as moderate due to reliance on observational data and heterogeneity across studies. Evidence for reduction in bleeding and vascular complications was rated as high certainty, given consistent findings across multiple study designs. Evidence for procedural metrics and subgroup effects was rated as low to moderate certainty. Discussion This systematic review and meta-analysis demonstrates that radial access is associated with improved long-term clinical outcomes compared with femoral access in STEMI patients undergoing PCI. The observed mortality benefit likely reflects sustained effects of reduced bleeding complications, which are strongly associated with adverse prognosis [ 3 , 4 , 10 ]. These findings are consistent with contemporary guideline recommendations endorsing RA as the preferred access strategy [ 2 , 9 ]. Importantly, benefits appear most pronounced in high-risk populations, reinforcing the clinical importance of access-site selection. Although heterogeneity was substantial, the direction of effect consistently favoured RA across studies, supporting the robustness of the findings. Limitations This analysis is limited by the predominance of observational data and substantial heterogeneity. Definitions of secondary outcomes varied, and operator experience was inconsistently reported, potentially influencing outcomes [ 15 ]. Conclusion In STEMI patients undergoing PCI, radial access is associated with superior long-term clinical outcomes compared with femoral access, including reduced all-cause mortality and fewer bleeding complications. These findings support current guideline recommendations favoring radial access as the default vascular strategy. Abbreviations STEMI ST–segment elevation myocardial infarction PCI Percutaneous coronary intervention RA Radial access FA Femoral access MACE Major adverse cardiovascular events RCT Randomized controlled trial CI Confidence interval RR Risk ratio Declarations Human Ethics and Consent to Participate Not applicable. Funding This research received no external funding. References Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet. 2003;361:13–20. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119–177. Rao SV, O’Grady K, Pieper KS, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol. 2005;96:1200–1206. Ndrepepa G, Berger PB, Mehilli J, et al. Periprocedural bleeding and 1-year outcome after PCI. Eur Heart J. 2008;29:2412–2421. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography in acute coronary syndromes (RIVAL). Lancet. 2011;377:1409–1420. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-elevation acute coronary syndrome (RIFLE-STEACS). J Am Coll Cardiol. 2012;60:2481–2489. Bernat I, Horak D, Stasek J, et al. Radial versus femoral access in STEMI. J Am Coll Cardiol. 2014;63:964–972. Valgimigli M, Gagnor A, Frigoli E, et al. Radial versus femoral access in acute coronary syndromes (MATRIX). Lancet. 2015;385:2465–2476. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87–165. Kwok CS, Rashid M, Fraser D, et al. Access site complications following coronary procedures: a systematic review and meta-analysis. J Am Heart Assoc. 2016;5:e003629. Bajraktari G, Rexhaj Z, et al. Radial access carries fewer complications compared with femoral access: a meta-analysis. J Clin Med. 2021. Lee WJ, et al. Long-term mortality in patients undergoing PCI via radial vs femoral access. JACC Cardiovasc Interv. 2023. Fazel R, Rao SV, Cohen DJ, et al. Temporal trends in outcomes of radial versus femoral access in the USA. Eur Heart J. 2025. Page MJ, McKenzie JE, Bossuyt PM, et al. PRISMA 2020 statement. BMJ. 2021;372:n71. Higgins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3. 2022. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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15:22:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858848,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8751873/v1/32f57e30-24ed-4aed-8f73-2df80fbc5cbe.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eRadial versus femoral access and long-term outcomes in ST-segment elevation myocardial infarction: a systematic review and meta-analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary PCI is the preferred reperfusion strategy for patients presenting with STEMI and has demonstrated superior survival compared with thrombolytic therapy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite advances in pharmacotherapy and device technology, access-site complications remain an important contributor to adverse outcomes.\u003c/p\u003e \u003cp\u003eFemoral access has traditionally been the default approach for PCI but is associated with higher rates of access-site bleeding and vascular complications. Such bleeding events have been independently linked to increased short- and long-term mortality in acute coronary syndrome populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRadial access allows rapid haemostasis and minimizes the risk of major access-site bleeding. Large randomized trials and observational studies have consistently demonstrated lower bleeding rates and improved short-term outcomes with RA compared with FA in STEMI patients [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These findings have informed contemporary guideline recommendations advocating RA as the preferred access strategy for PCI [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, whether these early benefits translate into sustained long-term clinical advantages remains uncertain. Existing studies evaluating long-term outcomes have reported inconsistent findings, and prior meta-analyses have focused predominantly on short-term endpoints or mixed acute coronary syndrome populations [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, a focused synthesis of long-term evidence in STEMI is warranted.\u003c/p\u003e \u003cp\u003eThis systematic review and meta-analysis aims to compare long-term clinical outcomes between radial and femoral access in STEMI patients undergoing PCI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThi study was conducted in accordance with PRISMA 2020 guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLiterature Search\u003c/h2\u003e \u003cp\u003eMEDLINE, Embase, and Cochrane CENTRAL were systematically searched from inception to the most recent update. Search terms included \u0026ldquo;ST-segment elevation myocardial infarction,\u0026rdquo; \u0026ldquo;radial access,\u0026rdquo; \u0026ldquo;femoral access,\u0026rdquo; and \u0026ldquo;percutaneous coronary intervention.\u0026rdquo; Reference lists of relevant articles were manually screened.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eStudies were included if they:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEnrolled adult STEMI patients undergoing PCI\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCompared RA and FA\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReported outcomes with \u0026ge;\u0026thinsp;30-day follow-up\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWere randomized controlled trials or observational cohort studies\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eData Extraction and Bias Assessment\u003c/h3\u003e\n\u003cp\u003eData were extracted using a standardized template. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized trials and the Newcastle\u0026ndash;Ottawa Scale for observational studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003e Meta-analysis was performed using Review Manager (RevMan 5.4). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed using the I\u0026sup2; statistic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy Selection\u003c/h2\u003e \u003cp\u003eA total of 407 records were identified through database searches. After removal of 278 duplicates, 129 titles and abstracts were screened, of which 76 were excluded. Fifty-three full-text articles were assessed for eligibility; 10 could not be retrieved despite multiple attempts through institutional and interlibrary access, and 34 were excluded for not meeting inclusion criteria. Ultimately, nine studies met the eligibility criteria and were included in the final synthesis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Characteristics\u003c/h3\u003e\n\u003cp\u003eNine studies were included, comprising seven observational cohort studies and two randomized controlled trials. Studies were published between 2012 and 2023 and conducted across diverse geographic regions including Europe, Asia, North America, and South America. All studies enrolled patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) and compared radial versus femoral vascular access.\u003c/p\u003e \u003cp\u003eSample sizes ranged from 307 to 16,614 patients, with follow-up durations between 30 days and 5 years. Long-term outcomes (\u0026ge;\u0026thinsp;30 days) were reported in eight studies. Outcomes assessed included all-cause mortality, major adverse cardiovascular events (MACE), bleeding complications, recurrent myocardial infarction, stroke, and procedural metrics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of characteristics of included studies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthor (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSTEMI Only?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFollow-up Duration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMain Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRisk of Bias\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRuano-Ravina A\u0026thinsp;\u0026minus;\u0026thinsp;2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1461 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 days and 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAll-cause mortality at 30 days and 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMori H\u0026thinsp;\u0026minus;\u0026thinsp;2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProspective multicenter registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,802 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 days and 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMACE, death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow - modarate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRomagnoli E \u0026ndash; 2012 (RIFLE-STEACS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eItaly and Netherlans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1001 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMACE and death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYamashita Y \u0026ndash; 2017 (OCEAN RACE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMulticenter observational registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,662 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDeath, MI and stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAndrade PB\u0026thinsp;\u0026minus;\u0026thinsp;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProspective observational registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e588 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDeath, MI and stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValgimigli M \u0026ndash; 2015 (MARTIX)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultinational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLarge RCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,404 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes (subgroup)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 days and 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMACE and death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRodriguez-Leor O\u0026thinsp;\u0026minus;\u0026thinsp;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProspective single-center observational registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e307 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes (but very small femoral group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMACE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKedev S\u0026thinsp;\u0026minus;\u0026thinsp;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRepublic of Macedonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSingle-center prospective observational registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,808 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMortality and MACE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGunarathne A\u0026thinsp;\u0026minus;\u0026thinsp;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrospective observational registry analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,951 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow - modarate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eRisk of Bias Assessment\u003c/h3\u003e\n\u003cp\u003eThe seven observational studies were assessed using the Newcastle\u0026ndash;Ottawa Scale and were judged to be at low overall risk of bias, with most scoring 8\u0026ndash;9 stars. Common strengths included representative patient selection and reliable outcome ascertainment. Limitations primarily related to residual confounding.\u003c/p\u003e \u003cp\u003eThe two randomized controlled trials (SAFARI-STEMI and OCEAN RACE) were assessed using the Cochrane RoB 2 tool and were judged to have low overall risk of bias. Randomization procedures and outcome reporting were adequate. Early termination of SAFARI-STEMI was noted but was not considered to materially affect the risk-of-bias judgment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eShort-Term Outcomes (\u0026le;\u0026thinsp;30 Days)\u003c/h2\u003e \u003cp\u003eShort-term outcomes were reported in all studies. The two randomized controlled trials demonstrated no statistically significant difference in 30-day all-cause mortality between radial and femoral access. In SAFARI-STEMI, mortality was 1.5% in the radial group versus 1.3% in the femoral group (p\u0026thinsp;=\u0026thinsp;0.69). Similar findings were reported in OCEAN RACE.\u003c/p\u003e \u003cp\u003eBleeding and access-site complications were consistently lower with radial access. Several cohort studies reported significantly reduced rates of major bleeding with radial access compared with femoral access. Vascular complications, including hematoma and pseudoaneurysm formation, were more frequent in the femoral access group across multiple studies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLong-Term Outcomes (\u0026gt;\u0026thinsp;30 Days)\u003c/h2\u003e \u003cp\u003eEight studies reported long-term follow-up outcomes ranging from 6 months to 5 years. Across these studies, radial access was generally associated with lower long-term all-cause mortality compared with femoral access. One large cohort study reported mortality rates of 18.7% in the radial group versus 32.6% in the femoral group over a median follow-up of 2.5 years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with adjusted analyses demonstrating a 22% reduction in mortality risk with radial access.\u003c/p\u003e \u003cp\u003eRates of MACE were consistently lower in the radial access group across most studies, although not all comparisons reached statistical significance. Components of MACE included cardiovascular death, reinfarction, stroke, and unplanned revascularization. No study demonstrated worse long-term outcomes with radial access.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMeta-Analysis of Long-Term Mortality\u003c/h2\u003e \u003cp\u003eA meta-analysis of eight studies reporting long-term all-cause mortality demonstrated a statistically significant reduction in mortality associated with radial access compared with femoral access (risk ratio [RR] 0.59, 95% confidence interval [CI] 0.38\u0026ndash;0.91; p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubstantial heterogeneity was observed (I\u0026sup2; = 93%), likely reflecting differences in study design, patient characteristics, follow-up duration, and outcome definitions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSecondary Outcomes: MACE and Bleeding\u003c/h2\u003e \u003cp\u003eMACE and bleeding outcomes were heterogeneously defined across studies and were therefore summarized descriptively. Most studies demonstrated lower MACE rates in patients treated via radial access. Bleeding outcomes consistently favored radial access, with significant reductions in major bleeding and vascular complications observed across randomized and observational data.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eProcedural Outcomes\u003c/h2\u003e \u003cp\u003eSix studies reported procedural metrics. Radial access was sometimes associated with slightly longer fluoroscopy time and higher contrast use, particularly in complex procedures. Access-site crossover from radial to femoral occurred in approximately 1.6\u0026ndash;5% of cases and was typically related to anatomical challenges. Several studies reported shorter hospital stays with radial access, often by 1\u0026ndash;2 days.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup Analyses\u003c/h2\u003e \u003cp\u003eSubgroup analyses reported in selected studies demonstrated that the benefits of radial access were maintained in elderly patients, women, and patients at high bleeding risk. These populations experienced lower bleeding rates and similar or improved long-term clinical outcomes compared with femoral access.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCertainty of Evidence\u003c/h2\u003e \u003cp\u003eUsing the GRADE framework, certainty of evidence for long-term mortality and MACE was rated as moderate due to reliance on observational data and heterogeneity across studies. Evidence for reduction in bleeding and vascular complications was rated as high certainty, given consistent findings across multiple study designs. Evidence for procedural metrics and subgroup effects was rated as low to moderate certainty.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review and meta-analysis demonstrates that radial access is associated with improved long-term clinical outcomes compared with femoral access in STEMI patients undergoing PCI. The observed mortality benefit likely reflects sustained effects of reduced bleeding complications, which are strongly associated with adverse prognosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings are consistent with contemporary guideline recommendations endorsing RA as the preferred access strategy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Importantly, benefits appear most pronounced in high-risk populations, reinforcing the clinical importance of access-site selection.\u003c/p\u003e \u003cp\u003eAlthough heterogeneity was substantial, the direction of effect consistently favoured RA across studies, supporting the robustness of the findings.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis analysis is limited by the predominance of observational data and substantial heterogeneity. Definitions of secondary outcomes varied, and operator experience was inconsistently reported, potentially influencing outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn STEMI patients undergoing PCI, radial access is associated with superior long-term clinical outcomes compared with femoral access, including reduced all-cause mortality and fewer bleeding complications. These findings support current guideline recommendations favoring radial access as the default vascular strategy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTEMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eST\u0026ndash;segment elevation myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous coronary intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRadial access\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFemoral access\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMACE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMajor adverse cardiovascular events\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRisk ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eHuman Ethics and Consent to Participate\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKeeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet. 2003;361:13\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eIbanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119\u0026ndash;177.\u003c/li\u003e\n \u003cli\u003eRao SV, O\u0026rsquo;Grady K, Pieper KS, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol. 2005;96:1200\u0026ndash;1206.\u003c/li\u003e\n \u003cli\u003eNdrepepa G, Berger PB, Mehilli J, et al. Periprocedural bleeding and 1-year outcome after PCI. Eur Heart J. 2008;29:2412\u0026ndash;2421.\u003c/li\u003e\n \u003cli\u003eJolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography in acute coronary syndromes (RIVAL). Lancet. 2011;377:1409\u0026ndash;1420.\u003c/li\u003e\n \u003cli\u003eRomagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-elevation acute coronary syndrome (RIFLE-STEACS). J Am Coll Cardiol. 2012;60:2481\u0026ndash;2489.\u003c/li\u003e\n \u003cli\u003eBernat I, Horak D, Stasek J, et al. Radial versus femoral access in STEMI. J Am Coll Cardiol. 2014;63:964\u0026ndash;972.\u003c/li\u003e\n \u003cli\u003eValgimigli M, Gagnor A, Frigoli E, et al. Radial versus femoral access in acute coronary syndromes (MATRIX). Lancet. 2015;385:2465\u0026ndash;2476.\u003c/li\u003e\n \u003cli\u003eNeumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87\u0026ndash;165.\u003c/li\u003e\n \u003cli\u003eKwok CS, Rashid M, Fraser D, et al. Access site complications following coronary procedures: a systematic review and meta-analysis. J Am Heart Assoc. 2016;5:e003629.\u003c/li\u003e\n \u003cli\u003eBajraktari G, Rexhaj Z, et al. Radial access carries fewer complications compared with femoral access: a meta-analysis. J Clin Med. 2021.\u003c/li\u003e\n \u003cli\u003eLee WJ, et al. Long-term mortality in patients undergoing PCI via radial vs femoral access. JACC Cardiovasc Interv. 2023.\u003c/li\u003e\n \u003cli\u003eFazel R, Rao SV, Cohen DJ, et al. Temporal trends in outcomes of radial versus femoral access in the USA. Eur Heart J. 2025.\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, et al. PRISMA 2020 statement. BMJ. 2021;372:n71.\u003c/li\u003e\n \u003cli\u003eHiggins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3. 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"King Saud bin Abdulaziz University for Health Sciences","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"STEMI, radial access, femoral access, PCI, long-term outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8751873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8751873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eRadial access (RA) and femoral access (FA) are both accepted vascular approaches for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). While RA is associated with lower short-term bleeding complications, its effect on long-term outcomes remains uncertain.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. MEDLINE, Embase, and Cochrane CENTRAL were searched for studies comparing RA and FA in STEMI patients undergoing PCI with follow-up \u0026ge;\u0026thinsp;30 days. Randomized controlled trials and observational cohort studies were included. Risk of bias was assessed using the Cochrane RoB 2 tool and the Newcastle\u0026ndash;Ottawa Scale. Long-term all-cause mortality was pooled using a random-effects model.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eNine studies were included, comprising two randomized trials and seven observational cohorts [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. RA was associated with a significant reduction in long-term all-cause mortality compared with FA (RR 0.59, 95% CI 0.38\u0026ndash;0.91; p\u0026thinsp;=\u0026thinsp;0.02), with substantial heterogeneity (I\u0026sup2; = 93%). MACE and bleeding complications were consistently lower with RA.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eIn STEMI patients undergoing PCI, radial access is associated with improved long-term outcomes compared with femoral access, supporting its role as the preferred access strategy.\u003c/p\u003e","manuscriptTitle":"Radial versus femoral access and long-term outcomes in ST-segment elevation myocardial infarction: a systematic review and meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 16:07:15","doi":"10.21203/rs.3.rs-8751873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dfc33491-c7e4-4622-a3eb-348c53ea1e50","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62093252,"name":"Cardiac \u0026 Cardiovascular Systems"},{"id":62093253,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2026-02-03T16:07:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 16:07:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8751873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8751873","identity":"rs-8751873","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}