104 year-old-female with cardiomyopathy, kyphoscoliosis, pleural effusion s/p thoracentesis, NSVT now presents with progressive exertional dyspnea (NYHA Class III) for few months. Patient underwent urgent balloon aortic valvuloplasty in August 2020 in setting of acute congestive heart failure and severe aortic stenosis. Recent transthoracic echocardiogram revealed LVEF of 35% and severe calcified aortic stenosis with AVA/PG/MG/PV of 0.35/74/48/4.3. Recent angiogram revealed non-obstructive CAD. CTA showed horizontal aorta with aortic annulus diameter of 18.8 mm X 23.6 mm (mean 21.2 mm), perimeter 66.6 mm and area 342.5 mm2. Her STS Risk for surgical AVR was 6.89%. Heart Team evaluation found her to be appropriate for TAVR despite advanced age. Analysis of lower extremity on CTA revealed severely calcified peripheral artery disease with diameter less than 5.5mm in b/l common iliac arteries. Now planned for TF-TAVR using 20mm SAPIEN S3 Ultra valve via left femoral percutaneous access with PTA of left common iliac artery.