Ruptured abdominal aortoiliac aneurysms, when treated with open surgical repair, have high morbidity and mortality rates. Since 1994, the authors have used endovascular approaches to treat this entity. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guide wire into the supraceliac aorta, and arteriography. If aortoiliac anatomy was suitable, an endovascular graft (stent-graft) repair was performed. If the anatomy was unfavorable, standard open repair was performed. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 35 patients treated in this manner, 29 underwent endovascular graft repair, and 6 required open repair. Four patients died within 30 days (operative mortality rate, 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. The authors believe these techniques will become widely used for the treatment of ruptured aneurysms.