The radial artery is a commonly used conduit in coronary artery bypass grafting (CABG) due to its favorable long-term patency. However, conventional open radial artery harvesting (ORAH) is associated with wound and neurological morbidity. Endoscopic radial artery harvesting (ERAH) has emerged as a minimally invasive alternative, but its comparative safety and efficacy remain uncertain. PubMed, ScienceDirect, and the Cochrane Library were systematically searched from inception to January 2026 for randomized controlled trials comparing ERAH with ORAH in patients undergoing CABG. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models. Primary outcomes included wound infection, overall wound complications, and neurological complications. Secondary outcomes included graft patency, hematoma, neurological deficit, stenosis, occlusion, and mortality. Eight randomized controlled trials involving 914 patients were included. ERAH was associated with a significantly lower risk of overall wound complications (RR: 0.51; 95% CI, 0.32-0.79; P = 0.003), hematoma (RR: 0.24; 95% CI, 0.07-0.78; P = 0.02), and neurological deficits (RR: 0.47; 95% CI, 0.36-0.62; P < 0.0001) compared with ORAH. No significant differences were observed in wound infection, overall neurological complications, graft patency, stenosis, occlusion, or mortality. ERAH reduces wound complications, hematoma, and neurological deficits without compromising graft patency or increasing mortality, supporting its use as a safe minimally invasive alternative to ORAH in CABG. Registration: PROSPERO (CRD420261333569).