Subclavian TAVI: more than an alternative access route.

The standard approach for transcatheter aortic valve implantation (TAVI) is through the transfemoral retrograde route, because it is minimally invasive and it is feasible under conscious sedation in a totally percutaneous fashion. When the transfemoral access is not feasible, the most used approaches are the transapical for the balloon-expandable Edwards SAPIEN XT valve, the subclavian for the Medtronic self-expandable CoreValve and the transaortic for both prostheses. We believe that the subclavian approach should be the first option to consider in patients with contraindications to the transfemoral approach, but also in those patients who appear at higher risk of vascular complications in the case of a feasible but difficult transfemoral approach. Although no direct comparison between the subclavian, transaortic and transapical approaches is available, in our opinion the subclavian access should be favoured, because of its lower invasiveness and its feasibility without general anaesthesia. The choice of vascular access should be taken by the Heart Team and should remain patient-centred rather than operator-preference driven.