While transfemoral access remains the preferred route for transcatheter aortic valve implantation (TAVI), a subset of patients presents with vascular anatomy or comorbidities that preclude this approach. This chapter provides a comprehensive overview of alternative access options—including transcaval, transaxillary/trans-subclavian (TS), transcarotid, transapical, and transaortic routes—detailing procedural techniques, patient selection criteria, and outcomes. Each method is discussed with a focus on anatomical considerations, pre-procedural imaging (notably computed tomography (CT) planning), and step-by-step procedural guidance. Emerging data show variable complication profiles across access types, with transaxillary and transcarotid approaches offering promising percutaneous alternatives, while transapical and transaortic options are more invasive but remain viable in selected high-risk patients. Despite higher procedural complexity and complication risks compared to transfemoral TAVI, these alternative routes allow for safe and effective treatment in patients who would otherwise be excluded from this life-saving therapy.