BackgroundDistal transradial access (dTRA) has been suggested to have great advantages over cTRA. However, there is a lack of preliminary data on dTRA in patients undergoing emergency coronary angiography (CAG) or percutaneous coronary intervention (PCI). To explore the feasibility and safety of distal transradial access in patients with acute chest pain.MethodsA total of 1269 patients complaining of acute chest pain in our emergency department from January 2020 to February 2022 were retrospectively included. The patients who met the inclusion criteria were divided into the conventional transradial access (cTRA) group (n= 238) and the dTRA group (n= 158). Propensity score matching was used to minimize the baseline differences.ResultsThe cannulation success rate in the dTRA group was significantly lower than that in the cTRA group (87.41% vs. 94.81%,p< 0.05). No significant differences in the puncture time and total procedure time were noted between the two groups (p> 0.05). Compared with the cTRA group, the hemostasis duration was significantly shorter [4(4, 4) h vs. 10(8, 10) h,p< 0.001) and the incidence of minor bleeding (BARC Type I and II) was significantly lower in the dTRA group than that in the cTRA group (0.85% vs. 5.48%,p= 0.045). Asymptomatic radial artery occlusion was observed in six patients (5.83%) in the cTRA group and one patient (1.14%) in the dTRA group (p= 0.126). The subgroup analysis of ST-elevation myocardial infarction (STEMI) showed no significant differences in the puncture time, D-to-B time or total procedure time between the two groups.ConclusionsThe dTRA for emergency CAG or PCI has an acceptable success rate and puncture time, a shorter hemostasis time, and a downward trend in RAO rate compared to the cTRA. The dTRA did not increase the D-to-B time in emergency coronary interventions in STEMI patients. On the contrary, a low incidence of RAO by the dTRA created an opportunity for future coronary interventions in non-culprit vessels in the same access.Trial registrationRetrospectively registered in Chinese Clinical Trial Registry (registry number: ChiCTR2200061104, date of registration: June 15, 2022).Supplementary InformationThe online version contains supplementary material available at 10.1186/s12877-023-04058-y.