Comparative outcomes of extrathoracic, intrathoracic and facilitated transfemoral access for transcatheter aortic valve implantation: a systematic review and meta-analysis
A Zaka, J Abtahi, D MutaharAbstract
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.