Alternative Access for TAVR - A State-of-the-Art Review and Practical Guide (JACC Cardiovascular Interventions October 2025)-Article: Alternative Access for TAVR - A State-of-the-Art Review and Practical Guide

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

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This 2025 state-of-the-art review comprehensively addresses alternative vascular access approaches for transcatheter aortic valve replacement (TAVR), focusing on decision-making beyond the standard transfemoral (TF) route. While TF access remains the guideline-recommended and dominant method—used in over 85% of cases—severe peripheral arterial disease (PAD), especially complex iliofemoral calcification and tortuosity, can preclude its safe use. The review highlights advances such as improved preprocedural computed tomography angiography (CTA), lower-profile delivery systems, and facilitated TF access techniques including intravascular lithotripsy (IVL) and orbital atherectomy, which have expanded TF eligibility even in challenging anatomies. However, determining when TF access poses unacceptable risk remains nuanced, guided by tools like the Hostile score evaluating PAD severity.<br /><br />For patients unsuitable for TF access, the review endorses prioritizing alternative transvascular routes—transaxillary, transcarotid, and transcaval—over transthoracic surgical methods (transaortic and transapical), which have significantly declined due to higher invasiveness and complications. Transaxillary access, often via surgical cutdown or percutaneous approach, is widely used in Europe with favorable success and mortality comparable to TF but potentially higher vascular complication and stroke rates in some studies. Transcarotid access, now the predominant non-TF route in the U.S., offers direct aortic valve approach with low stroke rates comparable to TF access, especially with careful patient selection including vessel size, plaque burden, and intact cerebral circulation. Transcaval access involves a novel percutaneous crossing from the inferior vena cava into the abdominal aorta, suitable for complex vascular anatomies, with excellent success but requiring specialized expertise and careful management of bleeding risks from aortocaval fistulas.<br /><br />Transthoracic approaches are reserved for rare cases with prohibitive transvascular access and involve surgical procedures with general anesthesia. They are associated with higher mortality, bleeding, and longer hospital stay compared to TF and alternative transvascular access.<br /><br />The review underscores the continuing move toward maximizing TF access, including facilitated techniques, while maintaining proficiency in at least one alternative transvascular access method tailored to institutional expertise. Future directions emphasize further refining patient selection, procedural innovations (new closure devices and calcium modification tools), and development of referral networks to centers with dedicated expertise for complex cases. Randomized trials comparing alternative access routes are unlikely due to low use rates, so registry data and expert consensus will guide practice.<br /><br />In sum, optimal TAVR access selection must balance individual anatomy, PAD severity, and local operator experience, favoring TF access when feasible, alternative transvascular routes as preferred non-TF options, and reserving transthoracic access as a last resort. Multidisciplinary planning and technical advances continue to improve outcomes for challenging anatomies.

Keywords

transcatheter aortic valve replacement

TAVR access routes

transfemoral access

peripheral arterial disease

alternative transvascular access

transaxillary access

transcarotid access

transcaval access

transthoracic access

vascular access decision-making