Background: The presentation of a ruptured fusiform abdominal aortic aneurysm (AAA) co-occurring with bilateral iliac dissections is extremely rare. Endovascular repair of ruptured AAA is an accepted treatment modality for suitable patients; however, this approach may be complicated by the presence of iliac arterial pathology. Methods and Results: We report the case of a 66-year-old man who presented with a ruptured AAA. Preoperative imaging demonstrated bilateral iliac artery dissections in addition to the ruptured AAA. We describe the technical aspects of the combined endovascular and open surgical repair required to manage this complex presentation. Conclusion: The combined presentation of ruptured AAA and bilateral iliac dissections has not been previously reported. Successful repair can be achieved using a combined endovascular and open surgical approach.