Current state of alternative access for transcatheter aortic valve implantation.

The transfemoral (TF) route constitutes the undisputed default access for transcatheter aortic valve implantation (TAVI). In patients in whom anatomical constraints preclude a TF approach, several alternative access routes have been used. Transthoracic (transapical and transaortic) access routes show higher mortality and bleeding complication rates than the TF approach, which is attributable to the higher baseline risk of the selected patients and the more invasive nature of these procedures. Alternative transarterial approaches (transaxillary, transcarotid, transinnominate) have demonstrated high technical success rates and a favourable safety profile in selected patients and are particularly valuable in the presence of poor respiratory function or previous cardiothoracic surgery. The transcaval approach is an innovative fully percutaneous approach that allows the introduction of large-bore sheaths and shows promising results in high-risk patients. Diligent procedural planning, appropriate patient selection and the expertise of the Heart Team allow the achievement of an adequate safety and efficacy profile of TAVI performed via alternative access. Future studies incorporating standardised and independent outcome assessment are required to gain further knowledge on the risk/benefit relation pertaining to the specific approaches and improve selection of the appropriate access route for the individual patient.