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Thoracic endovascular aortic repair will typically require adequate caliber iliofemoral arteries for device deployment. We describe the case of a patient with extensive iliofemoral disease, which necessitated transcaval delivery of an aortic graft to repair a distal aortic arch aneurysm. Our case report highlights the novel use of intravascular ultrasound to localize an optimal site for creation of an aortocaval connection and the subsequent use of a ventricular septal defect occluder to close the connection after successful stent deployment.