Transfemoral Versus Transaxillary Access for Transcatheter Aortic Valve Replacement in Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Abstract

Background & Objective: Transfemoral (TF) access is the standard approach for transcatheter aortic valve replacement (TAVR), whereas transaxillary (TAx) access is reserved for patients with unsuitable femoral anatomy. Although previous studies have compared these approaches in the general TAVR population, evidence specific to patients with heart failure with preserved ejection fraction (HFpEF) is limited. This systematic review and meta-analysis compared the safety and efficacy of TF and TAx access in HFpEF patients undergoing TAVR. Methodology: A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines. Observational studies comparing TF and TAx access in HFpEF patients undergoing TAVR were identified through a systematic literature search. Data extraction and quality assessment using the Newcastle-Ottawa Scale were performed independently by two reviewers. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models. Results: Seven studies involving 5,934 HFpEF patients (TF: 4,476; TAx: 1,458) were included. TAx access was associated with significantly lower risks of stroke (RR 0.44, 95% CI 0.26–0.73; P = 0.001), all-cause mortality (RR 0.51, 95% CI 0.34–0.74; P = 0.0005), and acute kidney injury (RR 0.56, 95% CI 0.38–0.82; P = 0.003). TF access demonstrated significantly shorter procedural time (MD −25.94 minutes, 95% CI −46.66 to −5.22; P = 0.01). No significant differences were observed in major vascular complications, major bleeding, procedural success, or new permanent pacemaker implantation. Conclusion: In HFpEF patients undergoing TAVR, TAx access was associated with lower risks of stroke, all-cause mortality, and acute kidney injury, whereas TF access offered shorter procedural duration. Both approaches demonstrated comparable procedural success and safety for other major outcomes. These findings suggest that access-site selection in HFpEF may benefit from an individualized approach, warranting confirmation in prospective studies. Key Words: TAVR, Transfemoral Access, Trans Axillary Access.