Alternative Aortic Access: Translumbar, Transapical, Subclavian, Conduit, and Transvenous Access to the Aorta

Large-caliber access to the arterial system is more frequently required in the age of thoracic endovascular aneurysm repair, endovascular aneurysm repair, and transaortic valve implantation. Frequently either anatomical or vessel size constraints preclude use of common access points such as the common femoral, radial, and brachial arteries. Alternative approaches include percutaneous access at alternate sites (subclavian, axillary, and carotid), open surgical access to the heart (left ventricular apex), open surgical access to large-caliber vessels (ascending aorta, subclavian, and axillary arteries, retroperitoneal access to the iliac artery or distal aorta), and novel percutaneous approaches (transvenous). Such approaches require additional skill sets, equipment, and, frequently, multidisciplinary teams to ensure safety and success. The techniques and approaches outlined in this article may allow expansion of endovascular treatments to greater patient populations and disease states than previously thought feasible.