Our findings suggest that the procedure time for TARE is significantly shorter with TRA compared to TFA. However, this conclusion should be approached with caution, as it is based on data from only two studies. Differences between the two approaches in terms of fluoroscopy time, air kerma, DAP, post-procedure pain in the recovery room, overall procedural pain, quality of life, and adverse events were statistically insignificant.

TRA has emerged as a promising alternative to TFA for various liver interventions, such as TACE and TARE for treating both primary and secondary hepatic tumors [6, 15, 17]. While TFA has traditionally been the preferred route for hepatic radioembolization, the success of TRA in coronary interventions demonstrating fewer access-related complications, greater patient satisfaction, and lower costs suggests its potential benefits for liver procedures as well [18,19,20].

However, there is a lack of high-quality evidence comparing TRA and TFA for non-coronary procedures. The existing literature, largely based on retrospective analyses, includes studies on TRA for TACE [17], TARE [16, 21], uterine fibroid embolization [22], prostatic artery embolization [23], and renal artery interventions [24]. These studies consistently demonstrate high technical success rates, shorter post-procedure recovery, shorter ambulation times, reduced bleeding risks, and improved patient comfort and satisfaction with TRA, similar to the benefits observed in coronary interventions.

Patient preferences and satisfaction with medical procedures are increasingly becoming the focus of research. In a retrospective study by Horn et al. (2016), among 67 patients who underwent both transradial access (TRA) and transfemoral access (TFA) for various procedures, 53 (79%) preferred TRA, while only 4 (6%) favored TFA, with 10 (15%) expressing no preference [25]. Similarly, a prospective study by Satti et al. [26] revealed that 24 out of 25 patients (96%) preferred radial access for cerebrovascular procedures. Furthermore, in a prospective study by Yamada et al., 29 of 36 patients (81%) opted for radial access over femoral access for liver cancer radioembolization [27]. However, despite these preferences, these studies did measure specific reasons influencing patient choices, such as pain, recovery time, or post-procedural quality of life.

Liu et al. (2019) investigated patient preferences and objectively assessed the impact of access sites on comfort and satisfaction during liver cancer radioembolization. Their study included patients with hepatocellular carcinoma who had experienced both TRA and TFA procedures. The findings revealed a strong preference for TRA, with 73.3% favoring radial access compared to 13.3% preferring femoral access and 13.3% having no preference. This preference likely stems from the study’s observation of significantly less pain with TRA during both the procedure and recovery. Additionally, TRA was associated with shorter recovery times, further contributing to patient satisfaction [16]. These findings highlight the importance of considering patient preferences when selecting the approach for hepatic interventions.

Current evidence regarding radiation exposure between TRA and TFA is controversial [16, 27], while large randomized trials in interventional cardiology have not found significant differences in patient radiation exposure measures, including fluoroscopy time, DAP, and air kerma, between TRA and TFA cardiac catheterization procedures [28, 29]. Similarly, studies on patient radiation exposure in non-coronary interventions, such as transarterial chemoembolization and prostatic artery embolization, have also found no differences in FT, DAP, or AK between the TRA and TFA approaches [14]. However, some large studies and meta-analyses in coronary interventions suggest that TRA is associated with higher radiation exposure compared with TFA [30, 31]. Although various technical parameters, such as protective devices and dose-reducing techniques [7], can help mitigate operator exposure during interventions, the impact of the vascular access site on operator radiation exposure remains unclear. This uncertainty persists even as more proceduralists begin to adopt TRA for complex vascular interventions.

Our meta-analysis addressed this conflict specifically focused on hepatic tumor radioembolization. The results are encouraging, demonstrating no significant differences in fluoroscopy time, air kerma, and DAP between TRA and TFA groups. This suggests comparable radiation exposure risk during radioembolization for patients with hepatic tumors by either access route.

Interestingly, our study revealed a contrast between the procedure time and fluoroscopy time. TRA showed significantly shorter procedure times but no significant difference in fluoroscopy time compared to TFA, this can be attributed to several factors. The overall procedure time includes both fluoroscopic and non-fluoroscopic components, and TRA may have more efficient non-fluoroscopic preparation and completion processes, leading to a shorter total procedure time despite similar fluoroscopy times. Additionally, operator experience with TRA, quicker vascular access and catheter manipulation, and the efficiency of support staff can streamline the overall procedure. However, the complexity of the procedures and the fluoroscopy usage itself remain comparable across both access routes, resulting in similar fluoroscopy times.

Furthermore, this disparity may be also explained by the smaller number of studies included in the analysis of procedure time, which comprised only two studies, compared to the analysis of fluoroscopy time, which included five studies. This difference in the number of studies could affect the statistical power and the robustness of the findings.

Regarding procedure time, Liu et al. [16] found no significant difference between TRA and TFA, which contrasts with our findings. However, Yakupog et al. [15] found a significant decrease with TRA, aligning with our results.

In terms of fluoroscopy time, studies by Bela Kis et al. [3], Loewenstern et al. [14], Liu et al. [16], Pedersoli et al. [6], and Yakupog et al. [15] all found no significant difference between TRA and TFA, which aligns with our findings.

For dose-area product (DAP), Bela Kis et al. [3], Liu et al. [16], and Loewenstern et al. [14] reported no significant difference between TRA and TFA, consistent with our results.

In the air kerma analysis, Bela Kis et al. [3] found a significant increase with TRA, while Yakupog et al. [15] found a significant decrease, contrasting with our findings. Liu et al. [16] and Loewenstern et al. [14] reported no significant difference, which aligns with our results.

Regarding overall pain during the procedure and pain in the recovery room, Liu et al. [16] found a significant decrease with TRA, contrasting with our findings. Yakupog et al. [15] found no significant difference, which aligns with our results.

For recovery time, Yakupog et al. [15] and Liu et al. [16] found a significant decrease with TRA, contrasting with our findings. Lastly, in terms of adverse events, Bela Kis et al. [3] and Yakupog et al. [15] found no significant difference between TRA and TFA, which aligns with our results.

The strength of our study lies in its comprehensive evaluation of TARE procedures for liver cancer treatment, with a comparative analysis of the TRA and TFA approaches. By synthesizing data from six included studies, which encompassed both retrospective cohort analyses and a RCT, and included a total of 1209 patients, we conducted a thorough examination of these interventions. Assessing 10 distinct outcomes, including patient radiation exposure, quality of life, and safety parameters, our study provided a robust analysis to determine which approach offers superiority in improving patient outcomes. Additionally, the focus on one hepatic intervention provides solid ground for clinical guidelines.

However, our study faced limitations due to the small number of included studies and variations in study design and patient populations, which could introduce biases and affect result generalizability. We encountered heterogeneity in some analyses and did not assess outcomes such as pain after the procedure, pain at home, or pain at the access site and perform cost analysis, as these were not reported in the studies. Additionally, some analyses were based on data from only two studies, which may impact the generalizability of our findings.

To address these limitations and advance the field of TARE for liver cancer, future research should focus on conducting well-designed RCTs with larger sample sizes to validate and strengthen our results. Studies should explore long-term outcomes, including tumor response rates, overall survival, and quality of life with different access approaches (transradial versus transfemoral). Investigating predictors of adverse events and patient outcomes could enhance patient selection and procedural planning. Furthermore, comparative studies on the cost-effectiveness of various access approaches would be valuable for healthcare decision-making. Continued research is essential to refine clinical practices and improve patient outcomes in TARE interventions.