Transfemoral TAVI in hostile access: experience with the paving and cracking technique

To the Editor, Femoral access is the preferred route for transcatheter aortic valve implantation (TAVI), according to the most recent clinical practice guidelines of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS).1 However, iliac vessel stenosis, tortuosity, and calcification may render transfemoral access unfeasible or lead to complications in up to 5%-10% of cases.2 To overcome these anatomical limitations, the paving and cracking (P&C) technique was described,3 originally used in endovascular aneurysm repair. This strategy allows preparation of the iliac vessels using covered stents followed by postdilatation.4 Other adjunctive techniques, such as intravascular lithotripsy,5 modify iliac vessel calcification and facilitate the advancement of large-bore introducer sheaths. We present our experience using the P&C technique to perform transfemoral TAVI in patients with hostile iliofemoral anatomy. We conducted a retrospective analysis of all patients who required adjunctive iliac endovascular treatment with covered stents (P&C technique) as part of transfemoral TAVI from 2021 through 2024 at our center. All cases were recorded in a prospectively maintained database including demographic variables, valve type and implantation characteristics, anesthetic technique, and procedural information. We analyzed preoperative computed tomography scans to assess maximum and minimum intraluminal iliac diameters, tortuosity, degree of calcification, and presence of...