Multiple studies have demonstrated lower access complications associated with transradial access (TRA) compared to transfemoral access (TFA) for endovascular procedures. The feasibility and safety of TRA versus TFA for mechanical thrombectomy (MT) for large vessel occlusions in acute ischemic stroke (AIS) is a subject of current debate.

We performed a systematic search in four databases. Binary outcomes were analyzed through odds ratios (OR) and 95 % confidence intervals (CI), while the continuous outcomes were analyzed through the standardized mean difference (SMD) and 95 % CI. Publication bias was visually assessed with a funnel plot and confirmed by Egger’s test.

There were 5048 total patients undergoing MT from 15 studies in our analyses. In these patients, 984 MT were via TRA and 4064 via TFA. Access-site complications (OR = 0.16, P-value < 0.01) was significantly lower in TRA than TFA. No significant difference was found in 90-day functional independence (mRS 0–2) in the primary analysis (OR = 0.83, P = 0.23), although sensitivity analysis indicated significant difference after resolving heterogeneity. There were no statistically significant distinctions observed between the TRA group and TFA group concerning successful recanalization (OR = 1.07, P-value = 0.5), access-to-reperfusion time (MD = -2.4, P-value = 0.43), first-pass effect (OR = 0.84, P-value = 0.06), mean number of passes (MD = 0.032, P-value = 0.66), symptomatic intracerebral hemorrhage (OR = 0.95, P-value = 0.8), and 90-day mortality (OR = 1.24, P-value = 0.28).

TRA was associated with fewer access-site complications compared to TFA. Although no significant difference in 90-day functional independence was observed in the primary meta-analysis, sensitivity analysis indicated potential superiority of TFA. Our findings highlighted optimizing the patient selection to maximize the benefits of thrombectomy through radial access. Further randomized trials and prospective studies are required to confirm these findings.