EDITORIAL The opinions expressed in this article are not necessarily those of the Editors of EuroIntervention or of the European Association of Percutaneous Cardiovascular Interventions. EuroIntervention 2020;15: e 1305- e 1306 published online e -edition February 2020 DOI: 10.4244/EIJV15I15A237 e 1305 © Europa Digital & Publishing 2020. All rights reserved. *Corresponding author: Service de Chirurgie Cardio-Vasculaire, Hôpital Cardiologique, CHRU de Lille, 2 Avenue Oscar Lambret, 59037 Lille, France. E-mail: thomas.modine@chru-lille.fr Do we need alternative access in TAVR anymore? Walid Ben Ali 1,2 , MD, PhD; Pavel Overtchouk 1 , MD; Thomas Modine 1 *, MD, PhD 1. Department of Cardiology and Cardiovascular Surgery, Heart Valve Center, Institut Cœur Poumon CHU de Lille, Lille, France; 2. Department of Cardiac Surgery, Montreal Heart Institute, Montreal, QC, Canada Transcatheter aortic valve replacement (TAVR) has expanded widely in recent years. The femoral access constitutes the gold standard and the first-line access for TAVR procedures 1,2 , allow- ing totally percutaneous procedures. Despite several iterations in device profiles and the improvement of TAVR techniques, 10 to 15% of patients are deemed ineligible for femoral access due to unfavourable femoral or aortic anatomy 3 . While the European guidelines 4 recommend the surgical option in intermediate-risk patients if the femoral access is not feasible, non-femoral periph- eral (nFP) accesses have emerged as alternatives to the femoral access, achieving comparable results in high-volume centres 5,6 with a trend towards more minimalist and less invasive proce- dures 7 . More recently, in a propensity-matched study, the French TAVR group 8 reported that nFP TAVR was associated with similar outcomes compared to transfemoral TAVR except for a twofold lower rate of major vascular complications and unplanned repairs, regardless of the centre volume. In this issue of EuroIntervention, two papers 9,10 report the results of two alternative nFP access routes for TAVR procedures. The first paper by Costa et al 9 reports the initial European experience of transcaval TAVR. Article, see page 1319 The authors conclude that transcaval access for TAVR is feasible and safe in patients not suitable for femoral access. In fact, 10% of patients experienced major vascular complications, which is quite high when compared with the results reported in the French registry 8 for nFP access (0.68%). Furthermore, about half of the patients had a residual aorto-caval shunt without any information on their midterm and long-term evolution. In this study, fifty patients were enrolled in five high-volume centres over a five- year period. This reflects the small number of potential candidates for this approach nowadays; this number will be even lower in the future. The second paper by van der Wulp et al 10 reports the results of 200 patients who had TAVR through a subclavian/axil- lary access with rates of 0.5% major vascular complications and 8.5% unplanned vascular repairs. Article, see page 1325 The authors developed a predictive model of vascular com- plications. A ratio of the sheath area to the axillary artery mini- mal lumen area >1.63 was found to be the strongest independent predictor of these complications. Although the developed model is very interesting, its discriminatory power remains intermedi- ate with an area under the curve of 0.67. The third nFP access for TAVR not addressed in these two papers is the transcarotid (TC) access. Surprisingly, the authors of the first paper 9 proposed the transcaval approach to their patients not suitable for either the transfemoral or axillary approach and did not first consider the TC approach. The TC-TAVR approach (Figure 1) represented 3.4% of patients treated with TAVR in the FRANCE TAVI registry 2 . The TC access has the potential to alleviate the drawbacks of the other nFP accesses. Indeed, the carotid artery is easily exposed. The clo- sure of the artery at the end of the procedure is performed with extreme simplicity using well-known vascular techniques. The short distance between the entry point and the aortic valve facil- itates the stability of the valve during the deployment. Patients