Development of stent-graft endovascular exclusion has forever changed the management of aortic aneurysms. This new modality is most advantageous for AAA patients who are at high risk for standard open repair. They, in turn, are more likely to present with challenging neck and iliac artery anatomy that may increase the likelihood of failure, and even preclude endoluminal therapy altogether. A complete understanding of critical anatomical issues and available troubleshooting adjunctive techniques is paramount if we are to expand applicability of stent-graft technology to increasing numbers of "difficult" patients with large aneurysms.
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