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Introduction: Patients with small caliber or otherwise hostile iliofemoral vasculature are at high risk for vascular injury when undergoing transcatheter aortic valve replacement (TAVR). Computed tomography angiography (CTA) guides alternative access feasibility including techniques such as transcaval access.

Methods: 339 patients (51.6% male, 87.0% white, age 79±1 years) who underwent TAVR at an urban tertiary care facility between 1/2/18 and 12/20/18 were retrospectively studied. Pre-procedure CTA of major vasculature was performed per institutional protocol. Femoral arteries with minimal luminal diameter (MLD)≤ 5.5 mm triggered alterative access planning for transcaval, transcarotid, transaxillary, and transseptal anterograde routes. Decision for alternative access was made by a multidisciplinary heart team consensus utilizing a “transcaval first” strategy.

Results: Of 339 patients, alternative access was used in 72 (21.2%) of patients with outcomes similar to transfemoral. Strategies were transcaval in 58 (17.1%), transcarotid in 10 (2.9%), transaxillary in 3 (0.9%), and transseptal anterograde in 1 (0.3%). Bilateral femoral arteries≤ 5.5 mm were present in 25 (7.4%) of patients.

Conclusions: CTA planning identifies patients who may benefit from transcaval access as a first line alternative access strategy.