There are no data regarding the feasibility and safety of a radial arterial approach with adjunctive urokinase for treating occluded autogenous radial-cephalic fistulas. We retrospectively examined 54 transradial interventions performed to treat occluded autogenous radial-cephalic fistulas within 72 h of occurrence. Urokinase was used in patients with a large thrombus burden. A total of 92 lesions in 54 consecutive patients (27 males, 27 females; mean age, 61.8+/-12.3 years) were treated via radial access. All radial punctures were successful except in one patient. Most thrombotic lesions were located within 1 cm of the radiocephalic anastomosis (79.6%). The mean length of treated thrombotic lesions was 10.3+/-5.4 cm (range, 4-32 cm). Twenty-five patients (46.3%) received urokinase (mean dose, 96,000+/-30,000 U). After transradial intervention, systolic, diastolic, and mean pressures in the radial artery decreased from 179+/-41, 77+/-17, and 111+/-22 mm Hg to 71+/-29, 36+/-15, and 48+/-19 mm Hg (all p's\0.001), respectively. Four radial interventions were unsuccessful. The anatomic and clinical success rates of the radial approach were both 92.6%; postinterventional primary patency rates were 65% at 6 months and 40% at 12 months. Two minor vascular complications were noted, one caused by guidewire-induced contrast extravasation and the other by balloon-induced contrast extravasation. No patient developed clinical signs of pulmonary embolism. In conclusion, the radial approach with adjunctive urokinase is an effective and safe approach to treat occluded autogenous radial-cephalic fistulas.