Abstract Body (Do not enter title and authors here): Background: Rotational atherectomy has been performed using both radial and femoral access over the years, but there is a lack of consensus on the safety and efficacy of these access sites.

Aim: To assess the safety and efficacy of radial access and femoral access.

Methods: MEDLINE, Scopus, and Cochrane Library were searched until May 2024 for studies comparing radial approach with femoral approach in patients undergoing rotational atherectomy. The primary outcome was major vascular site bleeding. Secondary outcomes included short-term mortality, long-term mortality, myocardial infarction, major adverse cardiovascular events (MACE), acute stent thrombosis, procedural success, procedural time, hospital stay and radiation exposure. Effect estimates were synthesized using a random-effects model and expressed as risk ratios (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with corresponding 95% confidence intervals (CIs).

Results: 13 studies including 13,581 patients with mean age of 60.76 years in the radial group and 66.86 years in the femoral group, who had undergone rotational atherectomy, were included in the analysis. For the outcome of major vascular site bleeding, there was significantly lower risk (RR: 0.25; 95% CI [0.15, 0.43]; p<0.00001) in the radial group as compared to the femoral group. From the secondary outcomes, MACE was found to be significantly lower (RR:0.80; 95% CI [0.68, 0.93]; p=0.004) in radial arm as compared to femoral arm. Radial group was also significantly associated with shorter procedural time (MD: -8.30 CI: 95% [-12.03, -4.56], p<0.00001) and hospital stay (MD: -2.30; 95% CI [-4.29, -0.30], p=0.02) as compared to femoral group. Whereas all the other secondary outcomes were found to be insignificant.

Conclusion: Rotational atherectomy using the radial approach significantly shows a lower rate of major vascular site bleeding and MACE and is also associated with shorter procedural time and hospital stay.