A 90-year-old woman with a history of end-stage renal disease secondary to hypertensive nephrosclerosis who underwent hemodialysis, a colectomy with end ileostomy for diverticulitis, and an endovascular aneurysm repair 6 years prior in another institution for a 6-cm infrarenal abdominal aortic aneurysm with an Ancure endograft (Guidant Corp, Menlo Park, California) presented with episodes of melena evident in her ileostomy bag. The aneurysm had increased more than 2 cm in diameter during the past 2 years. In the same institution, she had undergone 2 prior endovascular repairs with AneuRx limb extensions (Medtronics Inc, Minneapolis, Minnesota) placed in the right iliac artery for a type I distal endoleak that eventually occluded. She had adequate collateral flow requiring no revascularization of the right lower extremity. An intravenous contrast computed tomographic scan showed a large endoleak in an 8-cm aneurysmal sac. During an examination, it was determined that the patient had significant abdominal tenderness with minimal guarding. She was tachycardic but normotensive. She underwent an esophagogastroduodenoscopy (Figure 1).