Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access
Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access—especially in patients with peripheral artery diseas...
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MDPI AG
2025-05-01
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| author | Ioannis Skalidis Neila Sayah Thierry Unterseeh Thomas Hovasse Francesca Sanguineti Philippe Garot Youcef Lounes Antoinette Neylon Mariama Akodad |
| author_facet | Ioannis Skalidis Neila Sayah Thierry Unterseeh Thomas Hovasse Francesca Sanguineti Philippe Garot Youcef Lounes Antoinette Neylon Mariama Akodad |
| author_sort | Ioannis Skalidis |
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| description | Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access—especially in patients with peripheral artery disease (PAD)—pose significant challenges. Hostile vascular access, characterized by narrow vessel diameters, severe calcification, and tortuosity, complicates the procedure and necessitates alternative strategies. Recent advancements, such as intravascular lithotripsy (IVL), have shown promise in managing severely calcified arteries, improving the feasibility of transfemoral TAVR in patients previously considered ineligible. IVL uses pulsatile sonic waves to fragment arterial calcifications, enhancing vessel compliance and facilitating safe device delivery. Studies have demonstrated that IVL-assisted TAVR improves procedural success and reduces complications in patients with PAD. Additionally, orbital atherectomy, an adjunctive therapy targeting both concentric and eccentric calcifications, may complement the management of complex arterial calcification. The Hostile and passage–puncture scores offer valuable risk stratification tools for predicting vascular complications, aiding in better access site selection. Post-procedural echocardiography, particularly femoral artery sonography, may also play a role in detecting vascular complications early, enabling timely intervention. Finally, alternative access sites are increasingly being explored, with emerging data helping to guide the final access site decision. As TAVR continues to expand into lower risk populations, optimizing vascular access strategies remains essential to improving procedural outcomes. This review highlights the importance of preoperative imaging, endovascular techniques, and post-procedural monitoring in overcoming vascular challenges and ensuring successful TAVR outcomes. |
| format | Article |
| id | doaj-art-0ba0eeeae6214d158b29e98cc4382871 |
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| language | English |
| publishDate | 2025-05-01 |
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| series | Life |
| spelling | doaj-art-0ba0eeeae6214d158b29e98cc43828712025-08-20T02:33:47ZengMDPI AGLife2075-17292025-05-0115581010.3390/life15050810Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative AccessIoannis Skalidis0Neila Sayah1Thierry Unterseeh2Thomas Hovasse3Francesca Sanguineti4Philippe Garot5Youcef Lounes6Antoinette Neylon7Mariama Akodad8Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceInstitut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, FranceTranscatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access—especially in patients with peripheral artery disease (PAD)—pose significant challenges. Hostile vascular access, characterized by narrow vessel diameters, severe calcification, and tortuosity, complicates the procedure and necessitates alternative strategies. Recent advancements, such as intravascular lithotripsy (IVL), have shown promise in managing severely calcified arteries, improving the feasibility of transfemoral TAVR in patients previously considered ineligible. IVL uses pulsatile sonic waves to fragment arterial calcifications, enhancing vessel compliance and facilitating safe device delivery. Studies have demonstrated that IVL-assisted TAVR improves procedural success and reduces complications in patients with PAD. Additionally, orbital atherectomy, an adjunctive therapy targeting both concentric and eccentric calcifications, may complement the management of complex arterial calcification. The Hostile and passage–puncture scores offer valuable risk stratification tools for predicting vascular complications, aiding in better access site selection. Post-procedural echocardiography, particularly femoral artery sonography, may also play a role in detecting vascular complications early, enabling timely intervention. Finally, alternative access sites are increasingly being explored, with emerging data helping to guide the final access site decision. As TAVR continues to expand into lower risk populations, optimizing vascular access strategies remains essential to improving procedural outcomes. This review highlights the importance of preoperative imaging, endovascular techniques, and post-procedural monitoring in overcoming vascular challenges and ensuring successful TAVR outcomes.https://www.mdpi.com/2075-1729/15/5/810aortic stenosisalternative vascular accesscomplex femoral accessperipheral artery diseasetranscatheter aortic valve replacement |
| spellingShingle | Ioannis Skalidis Neila Sayah Thierry Unterseeh Thomas Hovasse Francesca Sanguineti Philippe Garot Youcef Lounes Antoinette Neylon Mariama Akodad Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access Life aortic stenosis alternative vascular access complex femoral access peripheral artery disease transcatheter aortic valve replacement |
| title | Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access |
| title_full | Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access |
| title_fullStr | Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access |
| title_full_unstemmed | Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access |
| title_short | Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access |
| title_sort | complex transfemoral access during transcatheter aortic valve replacement a narrative review of management complexity scores and alternative access |
| topic | aortic stenosis alternative vascular access complex femoral access peripheral artery disease transcatheter aortic valve replacement |
| url | https://www.mdpi.com/2075-1729/15/5/810 |
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