**1. Introduction**

Aortic valve is present between left ventricle and aorta. It opens during ventricular systole and closes at ventricular diastole.

Aortic stenosis (AS) represents obstruction of blood flow across the aortic valve due to congenital or acquired narrowing. Etiology can be bicuspid aortic valve, rheumatic aortic stenosis and senile aortic stenosis due to calcification of aortic valve.

It is a progressive disease that presents after a long subclinical period with symptoms of decreased exercise capacity, exertional chest pain (angina), syncope, and heart failure.

Echocardiography helps in diagnosis and grading of the aortic stenosis (**Table 1**).

Most of the patients usually undergo open surgical aortic valve replacement with mechanical or bioprosthetic aortic valve, but some patients may not be suitable


#### **Table 1.**

*Grading of aortic stenosis.*

candidate for the open surgical aortic valve replacement because of their associated comorbidities or risk of adverse outcome.

Transcatheter aortic valve implantation (TAVI) is the procedure of implanting the prosthetic aortic valve through intravascular route. First transcatheter aortic valve implantation was done by Cribier et al. [1].

It is the preferred procedure for the severe aortic stenosis patients who are being considered as non-operable [2] or high risk procedure [3] for open surgical aortic valve replacement.

It has become a well-established procedure over the years and since its invention over hundreds of thousands of valves has been deployed. This number is gradually increasing day by day.

There is a basic idea of a crimped aortic bioprosthetic valve and its transcatheter implantation in aortic valve position.

Followings (**Table 2**) are the aspects to be considered by the heart team to take decision for management of severe aortic stenosis in high risk patients for surgical aortic valve replacement or TAVI.

There are many ways of implanting the aortic valve (**Figure 1**) by TAVI but most commonly used route is retrograde transfemoral arterial access. This is less invasive and the only percutaneous way of implanting the aortic valve. Even it can be done without general anesthesia. Other routes need surgical cut down for the arterial access.

Peripheral vessels must be assessed for the size, tortuosity, and calcification of the iliac and femoral arteries. Vascular assessment is most commonly performed using contrast angiography or CT angiography. By default transfemoral access is considered to be vascular access site for TAVI.

Other retrograde transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. Existing data does not favor one route over another one. All the routes have different advantages and disadvantages.

This chapter will review the different accesses for aortic valve implantation.

Most common vascular access for TAVI is transfemoral artery by default. As the technology has improved, the options for the vascular access for TAVI has increased and may include transfemoral, transsubclavian (transaxillary), transapical, transaortic, and transcaval.

With the availability of the lower profile aortic valves for implantation, these valves are mostly deployed via transfemoral route but in case of contra-indication to use femoral artery for TAVI other vessels are used for access; as in case femoral arteries are of small size, tortuous or heavily calcified.

Before proceeding for TAVI, patient should undergo full work up with coronary angiography, CT angiography scan of heart, aorta and peripheral vessels, transthoracic and transesophageal echocardiography, lab investigations and other radiological investigations.

**5**

**Figure 1.**

*Different routes of aortic valve implantation by TAVI.*

**Table 2.**

*Different Sites of Vascular Access for Transcutaneous Aortic Valve Implantation (TAVI)*

*Factors to be considered in severe Aortic stenosis in high risk patients for Surgical AVR or TAVI.*

*DOI: http://dx.doi.org/10.5772/intechopen.84533*

*Different Sites of Vascular Access for Transcutaneous Aortic Valve Implantation (TAVI) DOI: http://dx.doi.org/10.5772/intechopen.84533*


#### **Table 2.**

*Vascular Access Surgery - Tips and Tricks*

comorbidities or risk of adverse outcome.

implantation in aortic valve position.

considered to be vascular access site for TAVI.

arteries are of small size, tortuous or heavily calcified.

aortic valve replacement or TAVI.

valve replacement.

*Grading of aortic stenosis.*

**Table 1.**

increasing day by day.

arterial access.

disadvantages.

aortic, and transcaval.

cal investigations.

valve implantation was done by Cribier et al. [1].

candidate for the open surgical aortic valve replacement because of their associated

Transcatheter aortic valve implantation (TAVI) is the procedure of implanting the prosthetic aortic valve through intravascular route. First transcatheter aortic

It is the preferred procedure for the severe aortic stenosis patients who are being considered as non-operable [2] or high risk procedure [3] for open surgical aortic

It has become a well-established procedure over the years and since its invention over hundreds of thousands of valves has been deployed. This number is gradually

There is a basic idea of a crimped aortic bioprosthetic valve and its transcatheter

Followings (**Table 2**) are the aspects to be considered by the heart team to take decision for management of severe aortic stenosis in high risk patients for surgical

There are many ways of implanting the aortic valve (**Figure 1**) by TAVI but most commonly used route is retrograde transfemoral arterial access. This is less invasive and the only percutaneous way of implanting the aortic valve. Even it can be done without general anesthesia. Other routes need surgical cut down for the

Peripheral vessels must be assessed for the size, tortuosity, and calcification of the iliac and femoral arteries. Vascular assessment is most commonly performed using contrast angiography or CT angiography. By default transfemoral access is

Other retrograde transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. Existing data does not favor one route over another one. All the routes have different advantages and

This chapter will review the different accesses for aortic valve implantation. Most common vascular access for TAVI is transfemoral artery by default. As the technology has improved, the options for the vascular access for TAVI has increased and may include transfemoral, transsubclavian (transaxillary), transapical, trans-

With the availability of the lower profile aortic valves for implantation, these valves are mostly deployed via transfemoral route but in case of contra-indication to use femoral artery for TAVI other vessels are used for access; as in case femoral

Before proceeding for TAVI, patient should undergo full work up with coronary angiography, CT angiography scan of heart, aorta and peripheral vessels, transthoracic and transesophageal echocardiography, lab investigations and other radiologi-

**4**

*Factors to be considered in severe Aortic stenosis in high risk patients for Surgical AVR or TAVI.*

**Figure 1.** *Different routes of aortic valve implantation by TAVI.*

Although in most of the TAVI procedures, Cardiopulmonary bypass (CPB) is not required but patient should have a full informed consent with possibility of emergency midline sternotomy and use of CPB in case of complications.

While it is difficult to predict which patients will need temporary CPB support during or after valve deployment, usually patients with ejection fraction (<25%) with severe pulmonary hypertension, especially those requiring significant inotropes during and after anesthetic induction are at higher risk.
