Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysm (rAAA) must be carried out instantly. This requires firm logistics that include the ability to cross-clamp the aorta without delay. The present article focuses on the technique of balloon control of the aorta in eEVAR with aspects on indications as well as the organization of this type of vascular service. Transfemoral insertion of the occlusion balloon under local anesthesia is advocated and described. The use of dual balloons shortens the time of visceral ischemia without necessitating repeat declamping until the aneurysm has been completely excluded. Staged declamping upon completion is necessary just as in open repair. A "balloon test" is suggested to better identify those high risk patients with a rAAA who may benefit from endovascular rAAA repair.