Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making

Purpose To describe emergency direct transabdominal aortic access as a bailout strategy for thoracic endovascular aortic repair (TEVAR) when bilateral iliac artery spasm precludes device delivery and contextualize this approach among contemporary access techniques. Case Report: A 58-year-old woman with a thoracic aortic pseudoaneurysm underwent planned TEVAR. Bilateral femoral cut-downs failed due to severe iliac artery spasm with > 50% luminal narrowing and contrast extravasation despite vasodilators and ballooning. After recognition of definitive access failure, emergency conversion to direct transabdominal aortic access was performed via midline laparotomy. A 21-French sheath was inserted under direct vision, enabling successful stent graft deployment. Postoperative recovery was uneventful, and one-month CTA confirmed complete pseudoaneurysm exclusion. Conclusion Iliac artery spasm is a dynamic and under-recognized cause of TEVAR access failure. Emergency direct transabdominal aortic puncture offers a rapid and definitive bailout solution, underscoring the importance of surgical preparedness and multidisciplinary coordination in complex endovascular therapy.