Cannulation of the contralateral gate during endovascular aneurysm repair (EVAR) is typically the rate-limiting step. We present two variations of a preloaded technique to facilitate gate cannulation in cases where anatomy can be prohibitive. A 55-year-old man presented with an acute infrarenal aortoiliac occlusion and lower extremity paralysis. After aortoiliac embolectomy, there was residual aortic thrombus. This was performed by advancing the hypogastric component over a stiff buddy wire as the main body was advanced over the aortic wire. The gate was compressed inside the nonaneurysmal aorta as expected, but a balloon was advanced over the preloaded wire to dilate the gate and to allow cannulation from the contralateral side. A Gore Excluder is partially loaded over the stiff wire into the sheath, stopping so that the distal end of the contralateral gate is still external. The first trigger wire is deployed so the end of the gate opens outside the sheath. A 5F sheath is used to externally cannulate the gate, and an 0.018-inch wire is passed through the gate as a preloaded wire.

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