Because of their small size, rotary left ventricular assist devices (LVADs) can be implanted through several alternative approaches, including transdiaphragmatic LVAD insertion through a left subcostal incision with anastomosis of the outflow graft to the retroperitoneal supra-celiac aorta and a left thoracotomy approach with anastomosis to the descending thoracic aorta. More recently we have added a counter-incision to allow the outflow graft of a transdiaphragmatic LVAD to be tunneled through the right chest and anastomosed to the ascending aorta. However, constructing a tension-free, nonkinking lie of the outflow graft can be challenging. We have found that placing a 10-cm to 15-cm length of polytetrafluoroethylene graft coaxially over the LVAD outflow graft ensures a smooth, kink-free lie. Thus far 12 patients have undergone reinforcement of the LVAD outflow graft prior to graft-to-aorta anastomosis. In all cases, graft lie was facilitated and kinking was eliminated.