Transaxillary Versus Transfemoral Access for Transcatheter Aortic Valve Implantation: A Propensity Score-Matched Comparison of Clinical Outcomes Using VARC-3 Endpoints

Abstract

Background/Objectives: Transaxillary access (TAx) is an established alternative to transfemoral access (TF) for transcatheter aortic valve implantation (TAVI) in patients with unfavorable iliofemoral anatomy. While TAx-TAVI has been increasingly adopted at experienced centers, propensity score-matched comparative data with VARC-3 endpoint definitions are scarce, and most existing series originate from Western European cohorts. We aimed to address this gap by reporting outcomes from a propensity-matched TAx versus TF cohort using VARC-3 endpoints, contributing contemporary data from a high-volume Turkish center with established alternative access expertise. Methods: Among 2389 consecutive TAVI procedures screened between January 2016 and December 2024, 291 patients with complete data were included. After stratification by access route (TAx n = 51; TF n = 240) and exclusion of one TAx patient with missing covariates, 1:2 greedy nearest-neighbor propensity score matching was performed using nine covariates. The final cohort comprised 150 patients (50 TAx, 100 TF). All outcomes were defined per VARC-3 criteria. Results: All nine covariates achieved standardized mean differences <0.1 after matching. Technical success was comparable (TAx 94.0% vs. TF 96.0%; p = 0.686). The VARC-3 early safety event rate did not differ significantly (16.0% vs. 15.0%; p = 1.000); no equivalence can be inferred given the small event counts and wide confidence intervals. Any bleeding (VARC-3) was significantly lower in the TAx group (8.0% vs. 22.0%; OR 0.31, 95% CI 0.10–0.95; p = 0.039), confirmed by conditional logistic regression for the matched structure (OR 0.32 [0.10–0.97]; p = 0.043); this should be considered an exploratory finding. Thirty-day all-cause mortality (encompassing in-hospital deaths) (6.0% vs. 10.0%; p = 0.545), 1-year mortality (12.0% vs. 16.0%; p = 0.628), and Kaplan–Meier 1-year survival (88.0% vs. 84.0%; log-rank p = 0.510) did not differ significantly. ICU stay (median 2 [1–2] vs. 2 [1–3] days; p = 0.020) and hospital stay (median 5 [4–6] vs. 5 [4–6] days; p = 0.005) yielded statistically significant p-values; however, medians were identical in both comparisons, and significance was driven by outlier-prolonged admissions in the TF group rather than a meaningful difference in typical recovery duration. Conclusions: TAx-TAVI demonstrated comparable mortality, safety, and hemodynamic outcomes to TF-TAVI, with a significantly lower rate of bleeding complications. Axillary access represents a safe and effective alternative route in patients unsuitable for transfemoral TAVI.