A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.