Comparative outcomes between transaxillary approach and thoracotomy-based approaches in TAVI with alternative access

TAVI has become the standard treatment for high-risk aortic stenosis. When transfemoral access is not feasible (approximately 10–15%), alternative approaches are used: transaxillary (subclavian artery, without thoracotomy), transapical (puncture of the ventricular apex via thoracotomy), and direct aortic (surgical access to the ascending aorta via mini-sternotomy or mini-thoracotomy). In this setting, comparative evidence between strategies is limited, and the choice often depends on the treating team.

This retrospective, multicenter study aimed to compare perioperative and mid-term outcomes between the transaxillary approach (non-thoracic access) and thoracotomy-based approaches (transapical -TA- and direct aortic -DA-) in patients without feasible transfemoral access. The study did not include the transcarotid approach, which is mentioned as an expanding alternative with a more direct trajectory to the aortic annulus and a potentially lower embolic risk.

The primary endpoint was all-cause mortality, and secondary endpoints included 30-day events (bleeding, stroke, and vascular complications).

A total of 198 patients were included from 2,185 TAVI procedures performed between April 2015 and April 2024 at three centers, of whom 97 were treated with the transaxillary approach and 101 with thoracotomy-based approaches (TA n=64; DA n=37). The mean age was approximately 83–84 years, with no significant differences in sex, frailty, or surgical risk between groups.

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In perioperative outcomes, the thoracotomy group showed greater procedural invasiveness: longer operative time (121±87 vs 78±18 minutes, p<0.001), higher transfusion requirement (34% vs 19%, p=0.002), greater total bleeding (28% vs 11%, p=0.007), and higher incidence of life-threatening bleeding (5.9% vs 0%, p=0.029), as well as a longer hospital stay (8.5 vs 5 days, p=0.003). Access-related complications were similar between groups (4.0% vs 5.1%, p=0.744). Ischemic stroke was more frequent in the transaxillary group (7.2% vs 1.0%), although not statistically significant (p=0.113). In-hospital mortality occurred only in the thoracotomy group (5% vs 0%, p=0.06).

During follow-up, one-year survival was significantly higher in the transaxillary group (91.1% vs 80.4%, p=0.04), with no differences in mid-term mortality (median survival 5.58 vs 4.76 years, p=0.78).

Transaxillary approach in TAVI: improved perioperative outcomes compared with thoracotomy-based access

In summary, the transaxillary approach is associated with better perioperative outcomes compared with thoracotomy-based accesses (transapical/direct aortic), with less bleeding, lower transfusion requirements, shorter operative time, and reduced hospital stay, as well as higher one-year survival. However, it shows a higher rate of ischemic stroke (7.2% vs 1.0%), although without statistical significance. Overall, these findings position it as one of the preferred alternative access routes when transfemoral access is not feasible, highlighting the importance of careful patient selection and thorough preprocedural vascular assessment to reduce neurological risk.

Original Title: Mid-term outcomes of trans-axillary versus thoracotomy approaches in alternative-access TAVR: a retrospective multicenter study.

Reference: Chiaki Aichi, Masahiro Inagaki, Junji Yanagisawa, Tetsuro Shimura, Masanori Yamamoto, Hideki Kitamura, Yutaka Koyama. Cardiovascular Intervention and Therapeutics, publicado online 2026. DOI: 10.1007/s12928-026-01253-7.