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At present the transfemoral approach is the most commonly used approach for TAVI worldwide. Alternative access routes such as direct aortic, subclavian or transapical approaches are of interest when the iliofemoral arteries are diseased, highly calcied or extremely tortuous. Comprehensive patient screening usingmultislice computed tomography and crossover techniques may reduce complication rates when using transfemoral approach, even for fully percutaneous procedures. Horizontal ascending aorta remains a challenge for retrograde valve crossing and device advancement as well as for accurate positioning during deployment. The buddy balloon technique is a simple option in the case of difcult aortic valve crossing with a delivery catheter, whereas the antegrade approach using the transapical route is a reasonable alternative in such anatomy.

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