ABSTRACT
Favorable clinical results combined with increased patient demand for minimally invasive surgery has resulted in an increased application of endovascular aortic aneurysm repair [EVAR], and this treatment modality is now being extended to younger, healthier patients. While it seems that EVAR is becoming a desirable option for many patients, it is essential to realize that the feasibility of the procedure may be limited at times by patient anatomy and technical difficulties. Specific anatomical difficulties can be imposed by difficult access, short tortuous and calcified aortic and iliac landing zones, and presence of coincident complex iliac aneurysms. Renal failure has also presented a concern for patients being considered for treatment with EVAR, as the contrast loads required for the procedure, as well as for continued postoperative surveillance, may place the patient at risk. We will discuss technical maneuvers and considerations when encountering difficult anatomy and challenging surgical procedures