In the modern era of transcatheter aortic valve implantation (TAVI), access is everything. As device profiles shrink and indications expand to younger, lower-risk patients, the anatomical and technical complexities of vascular access remain one of the most critical—and underappreciated—determinants of procedural success and safety.

While transfemoral access remains the default for most TAVI procedures, many patients present with challenging iliofemoral anatomy, severe calcification, tortuosity, or previous vascular interventions that make the pathway far from straightforward.

This blog explores practical, case-based strategies for navigating these challenges, and when it may be time to switch to alternative routes.

Case 1: Severe Calcified Iliacs, Narrow Lumen

Scenario:
80-year-old female with symptomatic aortic stenosis. CTA reveals heavy bilateral circumferential calcification of common and external iliac arteries with minimal luminal diameter <5.5 mm.

Challenges:

• Risk of rupture or dissection
• Difficulty with sheath advancement
• Inadequate expansion of closure devices

Solution Options:

• Pre-dilation with high-pressure balloon angioplasty
• Use of low-profile TAVI systems (14 Fr equivalent)
• Bilateral approach with staged iliac stenting pre-TAVI
• Consider transcaval access if no femoral option exists

Clinical Tip: In patients with hostile iliacs, pre-procedural ballooning can sometimes create just enough room—provided the vessel is not brittle with concentric calcium.

Case 2: Tortuosity and Kinking in Pelvic Vessels

Scenario:
Male patient, 75, with known peripheral vascular disease. CTA shows severe S-shaped kinking of external iliac arteries bilaterally.

Challenges:

• Difficulty in sheath tracking
• Higher risk of sheath kinking and delivery system misalignment
• Potential for procedural delay or device dislodgement

Solution Options:

• Stiff buddy wires to straighten vessels (e.g., Lunderquist)
• Ipsilateral balloon-assisted tracking
• Contralateral snaring for added support
• Switch to transaxillary or transcarotid route if tortuosity is severe

Clinical Tip: Avoid over-rotating the delivery system in tortuous vessels—this increases the risk of arterial injury and embolization.

Case 3: Previous Aorto-Femoral Bypass Graft

Scenario:
A 78-year-old male with prior aorto-bifemoral bypass. No native access due to complete occlusion of native iliac vessels.

Challenges:

• Inability to access true arterial pathway
• Bypass graft may not support large sheath insertion
• Unclear track for valve positioning

Solution Options:

• Transcarotid or axillary approach via surgical cutdown
• Direct aortic access (especially in those with prior bypasses)
• Transapical TAVI in select centers, though declining in use

Clinical Tip: Always perform a detailed CTA with 3D reconstruction in patients with prior vascular surgery. Understand the graft configuration thoroughly before choosing access.

Decision-Making Framework for Access Strategy

Evolving Techniques & Tools

• Transcaval access: A promising option in patients with no femoral route, allowing controlled crossing from IVC to aorta with plug closure post-procedure.
• Ultrasound-guided femoral puncture: Reduces complications in calcified or scarred groins.
• Vascular closure advancements: Devices like MANTA and PerQseal are designed for large-bore closure, even in challenging anatomies.

Beyond Anatomy: Patient-Centered Access Planning

Always consider:

• Antiplatelet/anticoagulation status
• Body habitus (especially for transaxillary or carotid)
• History of stroke, carotid stenosis
• Operator and institutional expertise in alternative access

A good access plan is not only anatomically feasible—it is procedurally safe, logistically realistic, and patient appropriate.

Final Thought: The Access Route Sets the Tone

A perfect valve deployment means little if the access fails.
Bleeding, dissection, and conversion to open repair all contribute significantly to morbidity in TAVI.

Great operators don’t just deploy valves—they build secure paths to get there.

At TriVasc Academy, we emphasize not only cutting-edge valve technologies, but also mastery of foundational access techniques. Because crossing the threshold safely is the first—and most crucial—step toward successful valve therapy.

Coming Soon on TriVasc Academy
Access planning checklists, CTA interpretation guides, and hands-on simulation modules for transfemoral, transcaval, and transaxillary approaches.