Impact of Severity and Extent of Iliofemoral Atherosclerosis on Clinical Outcomes in Patients Undergoing TAVR

Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access

Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access-especially in patients with peripheral artery disease (PAD)-pose significant challenges. Hostile vascular access, characterized by narrow vessel diameters, severe calcification, and tortuosity, complicates the procedure and necessitates alternative strategies. Recent advancements, such as intravascular lithotripsy (IVL), have shown promise in managing severely calcified arteries, improving the feasibility of transfemoral TAVR in patients previously considered ineligible. IVL uses pulsatile sonic waves to fragment arterial calcifications, enhancing vessel compliance and facilitating safe device delivery. Studies have demonstrated that IVL-assisted TAVR improves procedural success and reduces complications in patients with PAD. Additionally, orbital atherectomy, an adjunctive therapy targeting both concentric and eccentric calcifications, may complement the management of complex arterial calcification. The Hostile and passage-puncture scores offer valuable risk stratification tools for predicting vascular complications, aiding in better access site selection. Post-procedural echocardiography, particularly femoral artery sonography, may also play a role in detecting vascular complications early, enabling timely intervention. Finally, alternative access sites are increasingly being explored, with emerging data helping to guide the final access site decision. As TAVR continues to expand into lower risk populations, optimizing vascular access strategies remains essential to improving procedural outcomes. This review highlights the importance of preoperative imaging, endovascular techniques, and post-procedural monitoring in overcoming vascular challenges and ensuring successful TAVR outcomes.

Access Options for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) was introduced in 2002 and has become integral in the management of aortic stenosis. As an alternative to surgical aortic valve replacement, it relies heavily on safe access to the aortic annulus for implantation of a valve prosthesis. Throughout its development and in current practice, the transfemoral (TF) arterial route for retrograde valve delivery has been the primary approach. However, this route is not appropriate for all patients, which has led to the development of multiple alternate access options. This review discusses the development of access for TAVR, followed by a thorough discussion of TF access. The commercially available products, preprocedural planning, closure techniques, and procedural complications are all discussed. We also describe the various alternate access routes with particular emphasis on the most recently developed route, transcaval access (TCv), with focus on procedural indications, technical considerations, and comparative outcomes. As TAVR technology, indications, and availability all expand, the knowledge and implementation of safe access are of utmost importance.