Renal transplantation is the preferred treatment for end-stage renal disease (ESRD)
however, patients with significant vascular abnormalities may require innovative approaches to vascular anastomosis. This report describes a 72-year-old male with ESRD of unknown etiology who was assessed for a deceased donor kidney transplant. Severe atherosclerosis of the iliac arteries was identified on preoperative imaging, leading to the selection of the inferior epigastric artery (IEA) as the vascular conduit. Anastomosis was performed using interrupted 6-0 prolene sutures, resulting in successful graft reperfusion without intraoperative complications. Postoperatively, the patient experienced delayed graft function (DGF), remaining anuric for 10 days and requiring multiple hemodialysis sessions as well as antithymocyte globulin (ATG) therapy. Urine output resumed on the 10th postoperative day, and the patient was discharged two weeks after surgery. Despite initial challenges, including DGF requiring temporary dialysis, the patient achieved full recovery with stable graft function confirmed at follow-up. One-month follow-up with CT angiography confirmed satisfactory graft perfusion. This case underscores the feasibility of utilizing the IEA as an alternative vascular access in complex kidney transplantation, highlighting the critical importance of preoperative imaging, surgical adaptability, and the ongoing challenges of limited graft availability and long waiting times for transplant candidates.