Risk of bias assessment.

<p>Risk of bias assessment.</p

Main Characteristics of included trials.

<p>* Only patients treated with primary PCI were enrolled.</p>†<p>Glycoprotein IIb/IIIa inhibitors were not given in any of the patients because not approved for clinical use in Japan.</p>‡<p>STEMI patients receiving routine early PCI within 12 hours after thrombolysis were enrolled.</p><p>PCI, Percutaneous coronary intervention; ACS, Acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction; NSTEMI, Non-ST-segment elevation myocardial infarction; UA, Unstable angina; TFA, Transfemoral approach; TRA, Transradial approach; VCD, vascular closure devices; N.A., Not available data.</p

Flow diagram of trial selection.

<p>ACS, acute coronary syndrome.</p

Funnel plot for the primary endpoint.

<p>Funnel plot for the primary endpoint.</p

Effect of transradial vs. transfemoral approach on death.

<p><b>2A.</b> Odds ratio of death with transradial vs. transfemoral approach. The squares and the horizontal lines indicate the OR and the 95% CIs for each trial included; the size of each square is proportional to the statistical weight of a trial in the meta-analysis; diamond indicates the effect estimate derived from meta-analysis, with the centre indicating the point estimate and the left and the right ends the 95% CI. M-H, Mantel-Hænzel model; D+L, DerSimonian and Laird model. <b>2B.</b> Trial sequential analysis for death. Heterogeneity adjusted information size of 26,836 participants calculated on basis of death of 2.53% in the transfemoral group, relative risk reduction 20%, α = 5%, β = 20%, I² = 0%. Solid green cumulative Z-curve did not cross red dashed trial sequential monitoring boundaries for benefit or harm. Horizontal dotted green lines illustrate traditional level of statistical significance (p = 0.05).</p

Effect of transradial vs. transfemoral approach on major bleeding.

<p><b>4A</b>. Odds ratio of major bleeding with transradial vs. transfemoral approach. <b>4B</b>. Trial sequential analysis for major bleeding. Heterogeneity adjusted information size of 13,368 participants calculated on basis of major bleeding of 1.58% in the transfemoral group, relative risk reduction 35%, α = 5%, β = 20%, I² = 0%. Solid green cumulative Z-curve crossed both red dashed trial sequential monitoring and information size boundaries, thereby confirming that transradial approach is superior to transfemoral approach in reducing vascular complications. Horizontal dotted green lines illustrate traditional level of statistical significance (p = 0.05).</p