Background To determine whether transradial access (TRA) is as safe and efficacious as transfemoral access (TFA) in patients undergoing left main percutaneous coronary intervention (PCI). Patients and methods A systematic search of Medline, Embase, and the Cochrane Central Register of Controlled Trials databases was performed to indentify studies comparing TRA with TFA in left main PCI. The primary efficacy outcome was the incidence of major adverse cardiac events (MACEs) and the primary safety outcome was bleeding. Results Our systematic search identified eight nonrandomized studies including 2858 patients. The risk of MACEs was similar between TFA and TRA [unadjusted data: risk ratio (RR): 0.89; 95% confidence interval (CI): 0.71-1.10; P=0.27; propensity score matched data: RR: 0.97; 95% CI: 0.94-1.28; P=0.63], but PCI with TRA was associated with a significantly lower risk of bleeding (RR: 0.28; 95% CI: 0.17-0.47; P < 0.001). The risks of death, cardiac death, myocardial infarction, and target vessel revascularization were similar between the TRA and TFA groups, except for target lesion revascularization, which was lower in the TRA group. Conclusion In patients undergoing left main PCI, TRA was comparable to TFA in terms of MACEs, but was associated with a lower risk of bleeding. These results indicate that TRA could be the first choice for left main PCI in selected populations. Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.