Transsubclavian versus transfemoral TAVR with self-expanding valves

Transsubclavian (TS) access has emerged as a rapidly growing alternative to the traditional transfemoral (TF) approach in patients with hostile iliofemoral access undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate clinical outcomes following TS-TAVR and TF-TAVR in severe aortic valve stenosis treated with self-expanding devices.

We conducted a single-center retrospective analysis of consecutive patients undergoing TS- or TF-TAVR between August 2017 and May 2025 at our department. Clinical endpoints were reported according to the Valve Academic Research Consortium-3 (VARC 3) criteria.

A total of 817 patients underwent TF-TAVR, while 75 patients underwent TS-TAVR. Patients undergoing TS-TAVR were more frequently men, presented with a higher Euro Score II, and carried a greater burden of atherosclerotic disease. Unadjusted data analysis showed a significant association between TS access and 30-day mortality [HR 2.64, 95% CI: 1.00-6.97, p = 0.05], stroke [HR 2.44, 95% CI: 1.19-5.01, p = 0.01], myocardial infarction [HR 4.31, 95% CI: 1.16-15.96, p = 0.03], major bleeding [HR 1.79, 95% CI: 1.17-2.73, p = 0.007], and cardiovascular hospitalization [HR 1.65, 95% CI: 1.02-2.65, p = 0.01]. After risk adjustment, the access site remained independently associated with stroke and major bleeding, while 30-day mortality and cardiovascular hospitalization lost statistical significance.

Overall, TS-TAVR appears to be a feasible approach when TF-TAVR is not possible. Adjusted data revealed no statistically significant association with early mortality. However, the access site was significantly associated with stroke and major bleeding, findings likely attributable to the higher baseline risk of the subclavian cohort in our study.