We greatly appreciate the letter to the Editor by professor Deora [ ] and the interest in our article [ ]. It is true that treatment of female population and radiation exposure are issues of great importance and both may add considerations during the decision for cardiac catheterization access site. Females are underrepresented in all randomized trials and this is particularly true for trials comparing femoral and radial access for cardiac catheterization. In the two bigger studies addressing this question, the RIVAL [ ] and the MATRIX [ ] the female population was 26.5% and 26.6% respectively. The only study focused on the differences between radial and femoral approach in females was the SAFE PCI trial [ ]. The primary end point of the study, which was bleeding (BARC Types 2, 3 or 5) or vascular complications requiring intervention within 72 h post-procedure or at hospital discharge in patients undergoing PCI, was negative (1.2% vs 2.9%, p = 0.12). However, the same endpoint in the population undergoing cardiac catheterization with or without PCI was positive (0.6% vs 1.7%, p = 0.03). The high rates of switching from radial to femoral access observed in SAFE PCI and other randomized trials could be radically reduced in everyday practice, if all forearm access sites (radial, ulnar and distal radial) are utilized as possible alternatives, after initial radial access failure [ , ]. We should keep in mind that the most fragile of our patients are the ones that would benefit most from routines that may reduce the risk of bleeding, like the avoidance of femoral puncture.

Regarding exposure radiation in patients undergoing transradial cardiac catheterization, the data are conflicting. However, in the hands of experienced operators, the radiation exposure seems to be equal between transradial and tranfemoral procedures [ ]. The target of reducing radiation exposure during cardiac catheterizations for patients and health providers is of cornerstone significance. This target should not be achieved by reducing the use of forearm approach, but by adopting routines that reduce radiation exposure irrespective from the access site [ ].