Overcoming the Challenges of the Transfemoral Approach in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is performed through a retrograde transfemoral approach in approximately 80-90 % of cases thanks to the improvements in delivery catheter profile, size and steerability compared with the first generation devices. The aim of this review article is to describe the challenges of transfemoral TAVI and the options to overcome them. The difficulties may be related to the access itself or the placement of the valve using the transfemoral route. Comprehensive patient screening using multislice computed tomography and crossover techniques to prevent bleeding should result in low complication rates even for fully percutaneous procedures. Horizontal ascending aorta and severely calcified aortic valves remain a challenge for retrograde valve crossing, device advancement and accurate positioning during deployment. The buddy balloon technique is a simple option in the case of difficult aortic valve crossing with a delivery catheter, whereas an antegrade approach using the transapical route is a reasonable alternative in such anatomy.