[Complex femoral access in TAVI: From risk identification to alternative approaches]

Transcatheter aortic valve implantation (TAVI) has become the reference treatment for severe aortic stenosis across all surgical risk categories. Transfemoral access remains the default approach, but vascular complications, especially in patients with peripheral artery disease (PAD), can limit its feasibility. This review follows a three-step structure. First, when to suspect complex femoral access? The concept of "hostile" access (small calibre, severe calcification, tortuosity) and the Hostile and Passage-Puncture scores allow this risk to be stratified from preoperative imaging. Second, how to manage a complex femoral access? Intravascular lithotripsy (IVL) and orbital atherectomy expand eligibility for transfemoral access in severe calcified PAD, dedicated techniques (buddy wire, snare) address aortic and iliofemoral tortuosity, and careful puncture-site planning limits local complications. Third, when and which alternative access to consider when transfemoral access remains unfeasible? Transaxillary/subclavian, transcarotid, transcaval or, more rarely, transapical/transaortic, are associated with different risks and selection criteria. As TAVI expands to lower-risk populations, a structured vascular access strategy remains essential to procedural success and to decrease vascular complications.