Technical tips for managing difficult iliac access

Difficult iliac artery access remains one of the limiting factors in the successful application of endovascular management of abdominal and thoracic aortic pathologies. An understanding of the scope of the problem, as well as the recognition of patient characteristics that increase the likelihood of difficult access are paramount in preoperative planning. Herein we discuss the specific challenges of aorto-iliac access as well as provide a treatment algorithm for avoiding aorto-iliac complications. Alternative access strategies and emergency bail-out procedures are discussed. A thorough understanding of the preoperative anatomy and imaging is key to successful endovascular aortic surgery.