21 Mar 2026
When transfemoral TAVI is not an option: rethinking alternative access strategies
In this article, Ulrich Schäfer explores the evolving landscape of access strategies in transcatheter aortic valve implantation (TAVI). While the transfemoral approach remains the gold standard, a significant proportion of patients are not suitable due to peripheral vascular disease or anatomical constraints.
Drawing on clinical evidence and real-world practice, learn about the range of alternative access routes now available, from transaxillary and transcarotid to transcaval and direct aortic approaches, and their respective advantages, limitations, and outcomes.
Over the last two decades, transcatheter aortic valve implantation (TAVI) has emerged as a valuable treatment option (Class I, Level B) for patients with severe aortic stenosis (AS) who are at higher or moderate surgical risk for conventional aortic valve replacement with an age of ≥ 70 years.1 Nowadays, the most frequently used access route utilizes the common femoral artery. But whenever the transfemoral (TF) approach for TAVI or a surgical aortic valve replacement is not feasible, an alternative access route has to be considered (Class IIa LoE C).1
In recent years, the transapical (TA) approach has been largely displaced by other transvascular access routes, due to accumulating evidence that the TA approach is more likely associated with a higher morbidity compared to transvascular access routes.2 In this regard, a recent study comprising 129,821 patients of the national inpatient database (NID) of the United States (years 2011 to 2017) described the rapid decrease of TA utilization. After peaking numbers in 2013 at 27.7%, the counts declined to 1.92% in 2017, which was accompanied by a higher inpatient mortality, increased length of stay, and higher costs in those patients with TA-TAVI.3
Nevertheless, peripheral vascular disease is a common finding in patients who are candidates for TAVI.4 For transvascular TAVI sheath/introducer sizes range between 14F and 20F, depending on the valve size and the transcatheter heart valve (THV) delivery system. Thus, for most devices, a minimal vessel diameter of 5 to 6 mm is required. In addition, in at least 10 to 15% of TAVI patients, a transfemoral (TF) approach seems to be not advisable due to significant peripheral artery disease or severe vessel tortuosity. Hence, the direct aortic (Tao), transcarotid (TC), transcaval (TCav), and transaxillar (TAX) implantation routes have been developed and applied to a broader extent over the last decade, but these alternative access routes are still more frequently utilized in experienced high-volume centers.5-9
According to BiBa MedTech Research, the counts demonstrated a continuous rise between 2013 and 2025 for TF access utilization (in 2025: Europe 96%, Germany 94%; see figure 1). Conversely, the largest decrease was found for the TA access route (in 2025: Europe 1%, Germany 3%) with similarly stable counts for the TAX access route (in 2025: Europe 2%, Germany 1%), TC/TCav access route (in 2025: Europe 1%, Germany 1%), whereas the TAO access route seems no longer to be utilized in Europe and Germany, respectively.
Figure 1
Until today, there is a great amount of variability in access utilization among various centers with regard to their first and second choice of access for TAVI. In some hospitals, the TAX approach is used in up to 20% of the cases.10 Unfortunately, alternative TAVI approaches have not been studied in a comparative fashion, but available data suggest better outcomes for transvascular techniques compared to TA-TAVI (table 1). But the choice of alternative access routes depends still mainly on the experience and judgment of the heart team. Nevertheless, judgment of invasiveness varies among different investigators. Nevertheless, "central" access routes (e.g. TA and Tao) are associated with an even small thoracotomy, mandating intubation and ventilation, whereas other "peripheral" transvascular approaches allow for analgosedation and/or local anesthesia, only (figure 2).
Figure 2
The various levels of invasiveness with corresponding outcomes vary between different access approaches and are derived from the available literature (table 1).
Table 1
Apical | Aortic | Axillar | Axillar (perc.) | Carotid | Caval | |
|---|---|---|---|---|---|---|
Thourani 2015 | Babat 2016 | Petronio 2012 | Schäfer 2010, 2016 | Mylotte 2016 | Greenbaum 2016 | |
N | 4085 | 301 | 141 | 100 | 96 | 100 |
Centers | Many | 18 | 10 | 2 | 3 | 17 |
STS | 8.8 (5.8,13) | 9.0 ± 7.6 | no data | 7.2±5.2 | 7.1 ± 4.2 | 9.6 ± 6.3 |
LOS - days | 8.9 ± 6.4 | 9.9 ± 8.5 | no data | 7.9 ± 9.4 | 11 (9, 15) | 4 (2, 6) |
AKIN | 38.8% | 9.5% | 4.3% | 3 % | 7.3% | 3% |
LT Bleeding | no data | 3.4% | 7.8% | 0 % | 4.2% | 7% |
Vascular comp (maj.) | <1% | 3.4% | 2.2% | 1 % | 4.2% | 12% |
30-d Stroke/TIA | 2.4% | 1.3% | 2.1% | 1 % | 6.3% | 5% |
30-day Mortality | 8.8% | 6.1% | 5.7% | 6 % | 6.3% | 8% |
Notes | Self-reported | >5 cases prior to enrollment | Self-reported | Self-reported | No systematic imaging | Adjudicated / Systematic CT |
Moreover, practicability, ergonomics and costs differ between various access approaches, which have been presented at several scientific meetings and represent to some extent the opinion of the author (table 2).
Table 2
Apical | Aortic | Axillar | Carotid | Caval | |
|---|---|---|---|---|---|
Pain | Poor | Poor | Good | Good | Good |
Bleeding | Poor | Fair | Good | Good | Poor |
LOS | Poor | Poor | Good | Good | Fair |
Outcomes | Poor | Good | Good | Good | Fair |
Supportive Evidence | Good | Good | Good | Poor | Fair |
TAVI Ergonomics | Poor | Poor | Fair | Poor | Fair |
Procedure Complexity | Good | Fair | Fair | Fair | Poor |
Costs | Low | Low | Low | Low | Fair |
In summary
The frequencies of alternative access routes have been significantly declining in recent years, but they still serve as an important supplement for those patients in whom the TF access route is not advisable. Each alternative access has advantages and disadvantages, so the access route should be tailored to the patient's characteristics. However, there is no standardized algorithm for choosing the optimal alternative vascular access. In addition, the TA access seems to be limited to a very selected subset of patients with no other options. Possibly, TA-TAVI will be completely eliminated in the near future, since the industry is no longer pursuing sales in a significantly declining market.
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Conflict of Interest
U. Schäfer has received honoraria due to advisory board activities and grant support from Abbott Vascular, Medtronic Inc. New Valve Technology, Edwards Lifesciences, as well as honoraria from the speakers bureau of Edwards Lifesciences, Boston Scientific, New Valve Technology, Abbott Vascular, and Medtronic Inc.
