Mechanical thrombectomy (MT) is the standard of care for large vessel occlusions (LVO) in acute ischemic stroke (AIS), traditionally performed using transfemoral access (TFA). However, the sheathless transradial approach (sTRA) has emerged as a viable alternative, particularly for patients with complex vascular anatomies.

This systematic review and meta-analysis aim to evaluate the feasibility, efficacy, and safety of sTRA in MT for AIS.

We conducted a systematic review and meta-analysis following PRISMA guidelines, including observational studies that reported on MT using sTRA. Primary outcomes included the proportion of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] grade 2b-3), crossover rates from radial to femoral access, and symptomatic intracerebral hemorrhage (sICH). Secondary outcomes assessed were minor access site-related complications.

A total of four studies were included, comprising 138 patients who underwent MT with sTRA. The pooled analysis revealed a high rate of successful reperfusion (97%; 95% CI: 95–100%), with a low crossover rate to TFA (3%; 95% CI: 0–7%). The incidence of sICH was low, at 4% (95% CI: 0–8%), and minor access site-related complications occurred in 5% of patients (95% CI: 2–9%).

This meta-analysis demonstrates that sTRA is a feasible and effective approach for MT in AIS, with a favorable safety profile. The technique offers high recanalization rates, low complication rates, and minimal need for crossover to TFA. Future randomized controlled trials comparing MT with sTRA and TFA are needed to confirm these results and refine patient selection criteria for this approach. Despite encouraging results, the small number of included studies and their observational design limit the generalizability of the findings. Therefore, further comparative and randomized trials are needed to validate these outcomes.