A 79-year-old female patient was referred to our hospital for severe aortic stenosis and progressive exertional dyspnoea (NYHA stage III). She was known for hypertension, hypercholesterolaemia, bitroncular coronaropathy with a tight stenosis of the left anterior descending coronary artery, and non-significant stenosis of the circumflex artery, as well as for arterial insufficiency of the lower limbs (Leriche classification stage III) with stenting of both common iliac arteries a few years ago. At admission, the physical examination revealed signs of cardiac failure with oedema of the lower limbs and basal crackles on pulmonary auscultation. The rest of the physical examination was notable for a desaturation at 88% while breathing ambient air, a blood pressure at 96/55 mmHg (mean pressure, 68 mmHg) with a resting heart rate at 86 b.p.m. Systolic aortic murmur (4/6) radiating on the carotid arteries was detected at cardiac auscultation. The neurologic examination was normal. Laboratory findings are only relevant for an elevation of NT-pro-BNP at 2800 ng/L. Before being referred to our institution, an ergometry was performed. The patient stopped after an effort of 25 W (21% of predicted) because of dyspnoea, that represented 2.1 metabolic equivalent, which confirmed the poor physical condition of the patient. The coronarography revealed a bitroncular coronaropathy with tight stenosis (70–90%) of the proximal left descending anterior artery and a B1 stenosis (50–70%) of the first marginal artery. The pre-TAVI assessment was complemented in our institution with an ECG, a transthoracic echocardiography, a computed tomography (CT) angiogram and an angiological assessment. The ECG revealed a sinusal rhythm without any repolarization disorder. PR were 150 ms, and QRS were thin. The transthoracic echocardiography confirmed a severe high-gradient severe aortic stenosis with a mean gradient of 43 mmHg and valve area < 0.5 cm2 (). The left ventricular ejection fraction was preserved at 73% without any dyskinesia. Computed tomography-angiogram was performed for TAVI-planning. It revealed a calcic score at 1625. The aortic ring size was 19 × 23 mm and the ring area 338 mm². The CT showed a major diffuse thoraco-abdominal aorta atheromatosis with potentially emboligenic plaques with two juxta-renal stenotic segments reducing the lumen to respectively 4 and 5 mm (). The angiological assessment revealed a significant supra-aortic trunk arteriopathy. The patient presented a 50–69% stenosis of the right internal carotid (peak systolic velocity 250 cm/s, end-diastolic velocity 50 cm/s, and ratio internal carotid artery/common carotid artery 2.5) and a 70–99% stenosis of the left internal carotid (peak systolic velocity 450 cm/s, end-diastolic velocity 150 cm/s, and ratio internal carotid artery/common carotid artery 6.5). There were moderate stenosis (>50%) of both external carotid arteries. The patient’s risk assessment demonstrated a EuroScore II of 7.67%. She was recused for a surgical aortic replacement by the Heart Team. It was decided to perform a TAVI for this asymptomatic high-gradient severe aortic stenosis in a patient with high intraoperative risk. In patients with severe aorto-iliac disease or previous endografting, transfemoral access for TAVI can be challenging or even contraindicated. In the present case, the past medical history of stenting of both common iliac arteries and the diffuse abdominal aorta atheromatosis were particularly challenging. An alternative approach to the conventional TF-TAVI was needed. It was decided to perform a transcervical TAVI after performing an endarteriectomy of the left carotid bifurcation (). An incision of 8 cm was made along the anterior border of the sternocleidomastoid muscle which was retracted to expose the left carotid bifurcation. After administration of heparin (100 units/kg), the vascular surgeons of our institution performed a classical carotid endarteriectomy (CEA) of the left carotid bifurcation after clamping the common, the internal and external carotids. Great care was given to create a smooth distal transition in the remaining distal portion of the internal carotid artery to avoid the formation of an intimal flap. The arteriotomy was closed by an enlargement angioplasty polytetrafluoroethylene (PTFE) patch (). The carotid was de-aired and unclamped according to the classical technique. Thereafter, the cardiac surgery team performed a direct arterial puncture in the middle portion of the PTFE patch. After a small incision with a size 11 blade, the device was easily inserted. At the end of the procedure, the patch was repaired with a 6/0 Prolene running suture. The rest of the procedure went uneventfully. Two days after the TC-TAVI, the patient developed dyspnoea and a desaturation at 79% while breathing 3 L/min oxygen. The transthoracic echocardiography showed a D-shaping of the left ventricle, and the CT angiogram revealed a pulmonary embolism of the right lower lobe. The angiological assessment showed deep venous thrombosis. A diagnosis of secondary pulmonary embolism in the context of hospitalization was made, and therapeutic anticoagulation was instaured for 3 months with favourable evolution. The cardiac follow-up was good. The transthoracic echocardiography showed an improvement of the right overload with a decrease of the pulmonary artery pressures from 86 mmHg to 52 mmHg and a decrease of the D-shaping of the left ventricle. The aortic transvalvular gradient (max/mean) was 17/8 mmHg, and there was no paravalvular leakage. The patient was discharged from hospital with clopidogrel 75 mg and apixaban 5 mg 2×/day at Day 6. Until now, the patient remains asymptomatic and has well tolerated the TC-TAVI without any cardiac or neurological complications.