Taking a Detour: Step-by-Step Alternative Approaches to Transseptal Access

Transseptal puncture via a femoral vein and inferior vena cava (IVC) is a commonly performed procedure in multiple electrophysiology studies that require access to the left atrium or left ventricle. However, the standard approach is impossible in certain anatomies with IVC obstruction, such as congenital IVC interruption with azygos continuation and acquired obstruction. Here, we describe a step-by-step approach to alternative methods for transseptal access, including the transhepatic approach and superior approach from either the internal jugular vein or axillary vein. With careful review of multi-modal imaging and multidisciplinary preprocedural planning, these methods are feasible and safe alternatives to transseptal access.