Precision approach for transradial access during PCI: a state-of-the-art review.

The transradial approach (TRA) has become the preferred vascular access for coronary angiography and percutaneous coronary intervention (PCI), offering reductions in bleeding and vascular complications compared with the transfemoral approach, and lower mortality in patients with acute coronary syndromes (ACS). Technical refinements have further enhanced procedural success with TRA. Variations in puncture technique (ultrasound-guidance, through-and-through vs. single-wall technique) and the use of vasodilator "radial cocktails" can improve access success and reduce the risk of radial artery spasm (RAS), while adequate anticoagulation, appropriate sheath sizing, and optimized radial band removal techniques help to reduce radial artery occlusion (RAO). Alternative access strategies such as distal radial (dTRA) and ulnar approaches offer advantages including lower RAO rates and preservation of the proximal radial artery for future conduit use, though these techniques are limited by higher crossover rates, longer cannulation times, and the need for additional operator experience. Optimal intraprocedural anticoagulation in the TRA era remains uncertain, as the bleeding advantage of alternatives to unfractionated heparin may be attenuated given the inherently lower access-site bleeding risk. Procedural complications, including hematoma, RAS, RAO warrant prevention and prompt recognition. Future research should refine anticoagulation strategies, personalize access-site selection, and further evaluate dTRA and ulnar approaches as operator experience matures.