Alternative Percutaneous Access for Large Bore Devices

Common femoral artery access is the default strategy for large-bore interventional procedures, including temporary mechanical circulatory support implantation and structural heart therapies, based on superior outcomes and operator ease. However, the size and caliber of the iliofemoral arterial system are influenced by patient size, sex, and comorbidities. Small vessel caliber, significant calcification or atheroma, and severe tortuosity may place patients at prohibitively high risk or render common femoral access impossible. Given the rapid growth of large-bore transcatheter procedures, bleeding avoidance strategies are essential, and thus, novel mechanisms for large-bore access have evolved. This article will discuss the advantages, limitations, and methods of the 2 most common percutaneous large-bore alternative access strategies: transaxillary and transcaval access.