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An 83-year-old male patient was transferred for cardiovascular assessment after presenting with peripheral edema and progressive dyspnea. Through cardiologic auscultation, a grade III/VI systolic ejection murmur in the right second intercostal area was noted. Our patient had a history of coronary artery bypass graft surgeries, having undergone the surgery twice: first surgery was conducted 17 years ago and second 10 years ago. He was diagnosed with lower extremity arterial disease and had an AAA in the infrarenal region with a diameter of 32 mm. The electrocardiogram showed sinus rhythm and incomplete right bundle branch block, whereas blood test results were unremarkable. The transthoracic echocardiogram revealed left ventricular ejection fraction to be 40% with global hypokinesis, 72 mm Hg systolic maximum, and 51 mm Hg mean pressure gradient on the aortic valve. A three-dimensional computed tomography (CT) angiography showed that both common iliac arteries were totally occluded and highly calcified, and 70% stenosis was observed in the left subclavian artery. The diameters of both subclavian and axillary arteries were 4.5–4.6 mm and not suitable for TAVR. The two common carotid arteries were also extensively calcified and not suitable for vascular access. TcTAVR was decided to be the appropriate procedure by the Heart Team. Bilateral percutaneous femoral venous access and arterial access from left brachial artery were obtained. An internal mammary catheter (7 French, Launcher, Medtronic, Dublin, Ireland) was placed in the inferior vena cava, and a goose neck snare (25 mm) at the predetermined crossing site was placed in the aorta. We planned to go through the infrarenal aorta above the AAA and tried to cross with Astato XS 20 0.014 inch (Asahi, Tokyo, Japan) chronic total occlusion guidewire with the support of Finecross microcatheter (150 cm, Terumo, Japan) and Navicross (135 cm, Terumo, Japan) support catheters accompanied by electrocautery (50 watt, cutting mode) attached to the back end of the guidewire (Fig. 1). Unfortunately, we could not reach the infrarenal aorta owing to the presence of porcelain aorta. We were able to cross into the AAA with the amputated tip of Conquest Pro 12 (Asahi, Tokyo, Japan) CTO guidewire, and the guidewire was captured by the goose neck snare, thereby creating the caval-aortic connection (Video 1). We then dilated the calcified wall of the AAA with coronary noncompliant balloons of 2.5 and 3.0 mm diameters (Solarice, Medtronic, Minneapolis, USA). Finecross microcatheter and Navicross catheters were advanced to the descending aorta. Finally, a 0.035 inch extra support Lunderquist wire (Cook, USA) was advanced to the ascending aorta through Navicross support catheter, and an 18 French 60 cm braided sheath (Cook, Bloomington, USA) was

Transcaval transcatheter aortic valve replacement through abdominal aortic aneurysm in a patient with no option for other vascular access