External iliac artery dissection is a catastrophic complication during kidney transplant surgery. We present a technically challenging case of external iliac artery dissection that occurred in severely atherosclerotic vessels of a high-risk patient receiving his third kidney transplant. The intimal dissection constituted by the upstream application of a vascular clamp during the preparatory dissection ofthe vessels and progressed rapidly along the iliofemoral axis. The external iliac artery was severely diseased and in an irreparable condition, hence ligated and removed. After a common iliac endarterectomy, an iliofemoral polytetrafluoroethylene vascular graft interposition was performed. The transplant kidney was anastomosed directly on the vascular graft. Satisfactory lower limb vascularization and kidney transplant perfusion were achieved withouttechnical difficulties. The patient had an uneventful recovery without complications. The kidney transplant recipient retained stable graft function at 6 months postoperatively. This rare case highlights the benefit of a surgical strategy in a vascular emergency that threatens the lower limb during a kidney transplant, and we emphasize the technical details of the procedure. As patients with extended indications are accepted onto the transplant waiting list, it is important for transplant surgeons to acquire surgical skills of vascular graft interposition. A postoperative blood flow monitoring device may be beneficial in high-risk kidney transplant cases.