The standard techniques of endovascular aneurysm repair sometimes fail to produce atraumatic stent-graft delivery of hemostatic implantation, and additional maneuvers are required to avoid conversion to open repair. Between June 1996 and May 1997 elective endovascular aneurysm repair was performed in 33 high risk patients, using a Z-stent-based prosthesis. Challenging anatomic features included: short neck (< 15 mm) in four cases, angulated neck (> 60 degrees) in seven, iliac aneurysm in six, and iliac tortuosity (> 80 degrees) in 24. There were no deaths, no renal failure, no pulmonary failure, no graft thrombosis, no migration, and no conversions to open surgery. Deviations from standard technique were required to treat iliac artery dissection, iliac artery stenosis, and leaks resulting from proximal stent malalignment, proximal stent malposition, and distal stent malposition. The necessary adjunctive maneuvers included: additional stent placement, additional stent-graft placement, and balloon dilatation. Mean operating time was 191 +/- 72 min, mean contrast volume was 148 +/- 76 ml, and mean blood loss was 314 +/- 427 ml. Mean time from operation to discharge from the hospital was 3.5 +/- 1.67 days. These short-term results demonstrate that endovascular aneurysm repair is safe and effective in high risk patients, only if adjunctive maneuvers are available to supplement standard technique.