<h3>Introduction</h3> Intra-aortic balloon pump (IABP) insertion via axillary access is increasingly utilized given convenience to the patient. We present a case of innovative femoral IABP access that allowed for prolonged mechanical circulatory support and patient rehabilitation. <h3>Case presentation</h3> A 20s-year-old gentleman with non-ischemic cardiomyopathy, listed for heart transplantation on continuous dobutamine infusion, was admitted in ambulatory cardiogenic shock state. A left axillary artery 50 mL IABP was inserted to facilitate physical and nutritional rehabilitation. Over the subsequent 23 days, he encountered three IABP malfunction events requiring device replacement. Examination of the extracted devices demonstrated recurrent kinking in the proximal IABP shaft past the exit point from the axillary arteriotomy sheath. As such, it was felt that the axillary artery anatomy was preclusive of stable IABP function and a 50 mL IABP was inserted via the right femoral artery. We used the routine modified Seldinger method and ultrasound guidance to obtain arterial access. The IABP was inserted without an access sheath and secured using 3M™ Ioban 2™ Antimicrobial drape. The patient continued to respond well to IABP support hemodynamically, however, transplantation was delayed due to patient and donor pool characteristics. On hospital day 32, our cardiac physical therapy team began utilizing a tilt table for therapy to help the patient stand. Ambulation when then progressed to ambulating up to 3,500 feet in a single session by day 64 after femoral IABP insertion (figure 1). We observed no access site bleeding, infection, or ischemic events. The patient was offered durable mechanical support as a bridge to transplantation but decided to continue temporary support until he successfully underwent orthotopic heart transplantation on hospital day 125. <h3>Conclusion</h3> Our case is unique in being able to achieve ultra-long support safely via sheathless femoral arterial access while continuing to ambulate the patient daily to prevent deconditioning. This access approach may decrease complication risk and expand the use of this traditionally short-term insertion technique, for more long-term support.