Alternative Access for TAVR: A State-of-the-Art Review and Practical Guide

Current guideline recommendations for transcatheter aortic valve replacement are largely confined to procedures performed via transfemoral (TF) access. Major advances in preprocedural planning, delivery system technology, and procedural technique have led to substantial growth in TF access, even in complex vascular anatomies. However, determining the threshold beyond which TF access is either not feasible or carries unacceptable risk remains controversial. Furthermore, although alternative transvascular access routes have largely replaced surgical transthoracic approaches in patients unsuitable for TF access, the optimal alternative access route is still debated. Herein, the authors provide a state-of-the-art review of alternative access for TAVR, including the decision-making process between TF and non-TF approaches and the key elements of alternative access site selection and execution.