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

• Although rare, iliac artery spasms can prevent femoral TEVAR device delivery, particularly with large-bore sheaths. • Salvage direct transabdominal aortic access is effective when pharmacological and endovascular measures fail, particularly in vessel injury. • Preprocedural planning should include a hierarchy of bailout strategies with immediate surgical expertise required. • Multidisciplinary coordination is critical for the timely recognition of access failure and safe conversion to an open access. : To describe salvage direct transabdominal aortic access as a bailout strategy for thoracic endovascular aortic repair (TEVAR) when bilateral iliac artery spasm precludes device delivery and to contextualize this approach among contemporary access techniques. A 58-year-old woman with a symptomatic thoracic aortic pseudoaneurysm underwent TEVAR. Bilateral femoral surgical cut-downs failed because of severe iliac artery spasm with >50% luminal narrowing and contrast extravasation despite maximal vasodilators and balloon angioplasty attempts. After recognizing definitive access failure, conversion to direct transabdominal aortic access was performed via midline laparotomy. A 21-French sheath (outer diameter ∼7.8 mm) was inserted under direct vision, which enabled successful stent graft deployment. Postoperative recovery was uneventful, and one-month CTA confirmed complete pseudoaneurysm exclusion and healed iliac access sites. However, a longer-term follow-up is recommended to assess the durability of aortic puncture sites. : Iliac artery spasm is a dynamic and under-recognized cause of TEVAR failure. When conventional measures fail, salvage direct transabdominal aortic puncture offers a definitive solution, underscoring the importance of surgical preparedness and structured bailout algorithms in complex endovascular therapy.