I was recently asked by a surgeon if I thought it was necessary to directly cannulate the axillary artery with a Biomedicus cannula and perform an angiogram when the most accepted way is to place a side graft on the axillary artery and just perfuse. My response was,” if this is what you are comfortable with, then this is the technique that you should use.” Well on second thought, I do think that you should probably at least do an intra-operative angiogram on everyone that you perform axillary cannulation. If you look at the intraop angio that I demonstrate here, one can see that the axillary and subclavian artery are free of disease, but there is a total occlusion of the innominate artery. I know that you are probably thinking that the artery look dissected, but I assure you that it is not. The cannula was placed under direct vision. I no longer use a Seldinger technique to cannulate the axillary artery. I believe that there is a significant potential to damage this very fragile and delicate artery. Therefore, I have resorted to obtaining proximal and distal control of the artery and perform a direct cutdown prior to inserting the cannula which has the guidewire back loaded into it. Antegrade perfusion with a side graft in this case would have proven to be fatal.