The wise radialist's guide to optimal transfemoral access: Selection, performance, and troubleshooting

Transradial access (TRA) has reduced vascular access-site complication (VASC) and bleeding rates in patients undergoing coronary angiography and intervention. A “radial-first” approach should be adopted and indications of TRA extended in order to maximize its beneficial effect. However, in certain clinical scenarios, transfemoral access (TFA) is a preferable or a mandatory route to successfully perform the procedure. Since the widespread adoption of TRA, a paradoxical increase in VASC rates has been observed in patients undergoing TFA, which might be attributed to a combination of increased risk profile of both the procedures and the patients, and a loss of skills in securing TFA by those who are now default radial operators. In the present article we provide recommendations on how to optimize patient selection for TRA and TFA, how to manage access site crossover, and how to perform state-of-the-art femoral artery puncture.