This picture demonstrates a cannulation of the axillary artery in the axilla. In patients with large breasts, breast implants or an elevated right hemi-diaphragm ,a very useful positioning option is placing the right arm over the head.  Since my cannulation site of choice is the femoral artery, there would be an issue performing femoral cannulation in a patient with severe PVD.  As I have previously stated, my next choice would be the axillary/ subclavian artery which is usually accessed below the right  clavicle. This is obviously not possible when the arm is placed over the head. This picture demonstrates the axillary artery cannulated directly in the axilla.  As you can see, the artery takes an inferior and posterior course as it goes into the chest. It does look awkward but it is the direction that it needs to take.  This option was mentioned to me by another surgeon that came to visit me in the recent past. I made a 2cm incision in the crease of the axilla. The artery is easy to identify but care needs to be taken not to injury the brachial plexus with its very large nerves surrounding the artery. A 15 Fr Biomedicus cannula is usually sufficient to cannulate. I did perform an intra-operative angio to verify its location. In this particular patient, I performed a minimally invasive MVRepair/TVRepair.