Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstacles and challenges for more widespread adoption of the radial access site as the default access site in PPCI.