Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery. Recent demonstration of better outcome following preoperative IABP insertion in high-risk patients has further extended its indication. However, due to an increasing complexity of patients currently referred for cardiac surgery, several patients with potential indication for preoperative and/or postoperative IABP present severe peripheral vascular disease which usually contraindicates IABP insertion. Here we present an alternative technique for IABP insertion in patients with severe peripheral vessel disease.