Arterial variation relevant to transfemoral transcatheter aortic valve replacement (TF-TAVR): a cadaveric and literature based analysis.

PURPOSE: Transfemoral transcatheter aortic valve replacement (TF-TAVR) is the preferred vascular access route for aortic valve implantation, but procedural success is highly dependable on iliofemoral vascular anatomy. This study aimed to directly assess anatomic risk factors for TF-TAVR using cadaveric dissection and highlight their relevance in the context of imaging-based literature. METHODS: Thirty-two formalin-embalmed cadavers (64 limbs) were dissected to assess luminal diameters of the common femoral (CFA), external iliac (EIA), and common iliac arteries (CIA). Anatomical configurations of the femoral triangle, bifurcation patterns of the CFA, atherosclerotic burden, and sheath-to-artery ratios (SFAR, SEIAR, SCIAR) for 14–18 F sheath sizes were recorded. RESULTS: High CFA bifurcation and posteriorly originating deep arteries of the thigh (DAT) were present in 39.1% and 57.8% of limbs, respectively. Mean diameters were 8.44 ± 1.75 mm for the CFA, 7.90 ± 1.55 mm for the EIA, and 9.53 ± 1.97 mm for the CIA. SFAR and SEIAR values increased with sheath size, reaching high-risk thresholds (≥ 1.05) in up to 19.4% of cadavers for SFAR and 28.1% for SEIAR at 18 F. Female cadavers had significantly greater SFAR and SEIAR values across all sheath sizes (p < 0.007). Moderate-to-severe atherosclerosis was present in 11.3% of CFA specimens and was associated with significantly reduced CFA diameter (p < 0.001). CONCLUSIONS: Commonly used sheath sizes in TF-TAVR may approach or exceed anatomical thresholds in a subset of patients. These findings provide anatomical context that supports preprocedural imaging practices and may inform device development and procedural education, particularly with attention to sex-specific vascular differences.