Objectives: The aim of this review is to discuss different methods of working through subclavian, innominate and aortic arch anatomical challenges in order to increase the success rate of transradial approach (TRA). Background: Anatomical challenges in the subclavian, innominate and aortic arch regions are important reasons for failure of TRA. There is limited modern literature describing methods to overcome these challenges and reduce TRA failure. Methods: A number of primary subclavian, innominate and aortic arch anatomical challenges are identified and management techniques to overcome them are discussed. Results: Subclavian, innominate and aortic arch anatomical challenges can be divided into five subsets, including (1) tortuosity, (2) loop, (3) stenosis, (4) congenital aberrancy and (5) combined challenges. In depth discussion with supportive examples for the identification and management of these challenges are provided. Conclusions: Despite lower rates of bleeding and vascular complications as compared to transfemoral approach (TFA), the adoption of TRA has been relatively slow in part due to frustration from operator failure during the learning curve. Anatomical challenges of subclavian, innominate and aortic arch regions play an important role in TRA procedural failure. Using a simple, conceptual, framework to classify the anatomical or functional problem, and then applying a logical approach to these challenges can facilitate management and augment operator success rates for TRA