Vascular Access for Transcatheter Aortic Valve Replacement: Challenges and Novel Approaches

Transcatheter aortic aortic valve replacement (TAVR) enables minimally invasive treatment of severe aortic stenosis and is increasingly being used as an alternative to surgical AVR. Computed CT angiography enables procedural planning, including assessment of the aortic root anatomy and the peripheral vasculature. Ideally the procedure should be totally percutaneous, and most procedures are performed via transfemoral (TF) vascular access. Initially, surgical methods were used for achieving vascular access for valve implantation and subsequently for achieving access site hemostasis. Vascular closure devices (VCD) have obviated need for vascular surgery in most cases of TF TAVR. Miniaturization of valve delivery systems (currently to 14F caliber) has increased the number of patients who can be treated via TF access. Severe access site hemorrhage due to VCD failure may require emergency surgical vascular repair, however VCD failures can currently be treated by implantation of stent grafts in most cases. When peripheral vascular disease precludes TF vascular access, TAVR may be performed via alternative routes which include the subclavian artery, carotid artery, left ventricular apex, direct puncture of the ascending aorta, and transcaval access. Further reduction in device caliber and evolution of VCD technology are expected to increase the number of patients who undergo TAVR via TF access and to decrease the incidence of vascular access site complications.