Background Numerous large randomized trials have shown a significant morbidity and mortality benefit with the transradial approach (TRA) over the transfemoral approach (TFA) for endovascular procedures. However, this technique is routinely avoided or aborted due to unfamiliarity with the technique and the associated anatomical difficulties that may be faced in this approach. The objective of this review is to identify both the common and uncommon challenges that may be encountered during a transradial approach for cerebrovascular catheterization and to provide tips and tricks to overcome the transradial learning curve.

Method A careful review of the literature and of all our transradial cases was carried out to identify the common challenges and complications that are encountered when using TRA for diagnostic cerebral angiography and neurointerventions.

Results A stepwise approach is provided to prevent and manage common challenges including radial artery access failure, radial artery spasm, radial artery anomalies and tortuosity, radial artery occlusion, radial artery perforation and hematoma, subclavian tortuosity and anomalies, and catheter knots and kinks.

Conclusion The ability to recognize and navigate anatomical variations and complications unique to TRA will accelerate learning, decrease unnecessary morbidity and mortality, and further advance the neurovascular field.