AbstractBackgroundIn transcatheter aortic valve replacement (TAVR), transfemoral (TF) access offers several advantages over alternative access routes. Advances in sheaths and valve delivery technology have catalyzed the feasibility of TF‐TAVR, even in challenging anatomies.AimsReport procedural characteristics and outcomes of a TAVR program aiming for a 100% TF access rate.MethodsConsecutive patients undergoing TAVR were enrolled in a prospective registry. Equipment used to facilitate TF‐access in challenging anatomies included low‐profile sheaths, dilatators, peripheral balloons, covered and uncovered self‐expanding and balloon‐expandable stents, and intravascular lithotripsy (IVL).ResultsA total of 400 patients with a mean age of 81 ± 6 years (42% female) were analyzed. Minimal iliofemoral artery diameter (MLD) of the main access side was <5 mm in 42 (10.5%), extreme tortuosity was present in 65 (16.3%), and severe calcification in 59 (14.8%). TF‐access was successful in 399 (99.8%) patients. A transaxillary access was used in one patient. In multivariable analysis, an MLD < 5 mm was the strongest predictor for vascular complications (11.9% vs. 3.9%, OR: 3.86, 95% CI: 1.38−10.8, p = 0.01). Such patients also had more major/life‐threatening bleeding (14.2% vs. 3.1%, p < 0.001) and required more planned and unplanned peripheral interventions to enable TF access (35.8% vs. 3.4%, p < 0.001).ConclusionOur study shows that utilization of dedicated sheaths, peripheral balloons, stents, and IVL enables TAVR via TF access in >99% of patients. However, rates of vascular and bleeding complications in patients with narrow iliofemoral arteries (MLD < 5 mm) were high.