Key result
Intrathoracic TAVI access increases 30-day mortality ~90% vs extrathoracic access.
Why the study?
Severe peripheral arterial disease and hostile iliofemoral anatomy may preclude standard transfemoral TAVI access, requiring extrathoracic, intrathoracic, or facilitated transfemoral approaches. No randomised controlled trials directly compare these alternative strategies, and contemporary observational data regarding their relative safety and efficacy are inconsistent.
Does facilitated transfemoral access or extrathoracic access reduce 30-day all-cause mortality and procedural complications compared to intrathoracic access in patients undergoing TAVI with hostile iliofemoral anatomy?
Meta-Analysis (n=11,832)
Yes
Does facilitated transfemoral access or extrathoracic access reduce 30-day all-cause mortality and procedural complications compared to intrathoracic access in patients undergoing TAVI with hostile iliofemoral anatomy?
In TAVI patients with hostile iliofemoral anatomy, intrathoracic access carries significantly higher mortality, bleeding, and renal injury risks than extrathoracic access, whereas facilitated transfemoral access offers comparable early survival with fewer vascular and bleeding complications.
Supports avoiding intrathoracic access when alternatives exist; leaves open randomized confirmation of extrathoracic and facilitated transfemoral strategies.
Background Transfemoral access remains the primary route for transcatheter aortic valve implantation (TAVI), yet severe peripheral arterial disease and hostile iliofemoral anatomy may preclude this approach. Alternate strategies include non-femoral approaches such as extrathoracic (ET) and intrathoracic (IT) access, and facilitated transfemoral (TF) access enabled by percutaneous iliofemoral modification. There are no randomised controlled trials directly comparing these strategies, and contemporary observational data for relative safety and efficacy is inconsistent. This study aimed to compare safety and efficacy of non-femoral approaches and facilitated transfemoral access in TAVI. Methods This study was conducted in accordance with PRISMA guidelines. PubMed, EMBASE, Web of Science, and CENTRAL were searched through February 2026 for multivariable-adjusted or propensity-matched observational studies of facilitated TF (iliofemoral modification with angioplasty, stenting, and/or intravascular lithotripsy) versus non-femoral access (ET or IT). Three prespecified comparisons were performed: facilitated TF versus ET access, facilitated TF versus IT access, and ET versus IT access. The primary endpoint was all-cause mortality at 30 days. Secondary endpoints included stroke, major vascular complications, and acute kidney injury. Risk ratios (RR) were pooled using a random-effects model. Subgroup and sensitivity analyses explored IVL-facilitated versus non-IVL facilitation and endovascular versus transthoracic alternative access. Results Eighteen studies (n=11,832; intrathoracic [IT] n=6,800; extrathoracic [ET] n=5,032) were included. IT access was associated with higher 30-day mortality versus ET access (RR 1.90, 95% CI 1.56–2.30) and higher 1-year mortality (RR 1.31, 95% CI 1.21–1.42), with increased life-threatening bleeding (RR 1.71, 95% CI 1.41–2.07) and acute kidney injury requiring renal replacement therapy (RR 2.11, 95% CI 1.53–2.92), while risk of 30-day stroke was similar (RR 1.03, 95% CI 0.55–1.93). Facilitated TF was associated with a trend towards reduced mortality compared to ET access, but this did not achieve statistical significance (RR 0.70, 95% CI 0.39–1.27). Compared to IT access, facilitated TF was associated with reduced risk of major vascular complications (RR 0.45, 95% CI 0.35–0.60) and major bleeding (RR 0.34, 95% CI 0.25–0.48). Conclusion IT access was associated with increased 30-day mortality, bleeding and AKI compared with ET access, while facilitated TF access demonstrated similar early mortality and reduced vascular complications compared to ET access in appropriately selected patients. Larger-scale prospective studies are needed to further refine patient selection criteria and define optimal alternative access strategies.30-Day Mortality by TAVI AccessFor image description, please refer to the figure legend and surrounding text.
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Zaka et al. (2026) conducted a meta-analysis in Transcatheter aortic valve implantation (TAVI) in patients with severe peripheral arterial disease or hostile iliofemoral anatomy (n=11,832). Intrathoracic (IT) or facilitated transfemoral (TF) TAVI access vs. Extrathoracic (ET) TAVI access was evaluated on All-cause mortality at 30 days (RR 1.90, 95% CI 1.56-2.30). Intrathoracic TAVI access increased 30-day mortality vs extrathoracic access (RR 1.90, 95% CI 1.56-2.30), while facilitated transfemoral access had similar mortality (RR 0.70, 95% CI 0.39-1.27).
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