Aims: While major vascular complications (MVC) remains an issue after Transfemoral (TF) transcatheter aortic valve replacement (TAVR), we compared outcomes in TF versus transcarotid (TC) approaches in patients with complex vascular anatomy. Methods and results: Among patients undergoing TAVR in our center between 2015 and 2018, we evaluated patients with complex vascular anatomy defined on CT scan as: (a) iliofemoral diameter between 5.5 and 6 mm or <6.5 mm with severe calcifications or tortuosity AND/OR (b) abdominal aorta pathology. The primary endpoint included access failure, mortality, MVC, major bleeding and stroke at 1-month. Among 483 patients, 131 (31.2%) with complex vascular anatomy underwent TF (n = 51;39.2%) or TC (n = 80;60.8%) TAVR. The mean age was 81.7 ± 6.9. TC group had higher STS score (p = .01), higher incidence of coronary artery disease (p = .04) and lower left ventricular ejection fraction (p < .001). In TC group, primary endpoint occurred twice less without reaching significance compared to TF group (n = 8; 10.0% vs. n = 10; 19.6% respectively; p = .1). Incidence of MVC was higher in TF group (11.8 vs. 1.3% in the TC group; p = .01) with similar incidence of stroke between groups (p = .8). Conclusions: Despite higher patient risk profile, TC approach in complex aortofemoral anatomy provides similar favorable outcomes with less MVC compared to TF approach.