The transradial approach for management of hemodynamically unstable patients has been termed the “final frontier” of the radial approach. Even experienced radial operators continue to use the femoral approach in ST elevation myocardial infarction (STEMI) complicated by cardiogenic shock. In general, physicians site two reasons for preferring the femoral approach in STEMI patients with shock. The first is the fact that radial access may be more difficult and procedural failure rates may be higher in shock cases, a perception that is supported in several observational series. The second, and more important reason for many operators, is the belief that femoral access will facilitate the use of large caliber left ventricular (LV) support devices, which cannot be placed through the radial approach. Interventional cardiologists often feel that shock patients will need hemodynamic support and the use of the radial approach for coronary intervention will block support use. However, there is no data suggesting the radial approach is a handicap in STEMI complicated by shock. In contrast, there is an accumulating registry and randomized trial data set comparing the radial and femoral approach in unstable coronary syndromes. These series consistently point to an improved survival in the transradial cohorts. Instead of the common paradigm that unstable patients should be accessed via the femoral approach, one must contemplate whether choosing the femoral access in unstable patients potentially denies patients the clear survival advantage the radial approach confers. Finally from a practical standpoint, there is no prohibition to adding femoral access to cases begun from the radial approach, so that simultaneous dual access with radial approach for coronary intervention and femoral access for LV support is a reasonable strategy in many unstable patients.