Renal insufficiency and allergic reactions to contrast media are potential contraindications to angiography with conventional ionic iodinated contrast media in endovascular stent-graft placement. Real-time contrast medium-enhanced ultrasonographic (US) guidance of endovascular aortic repair might provide an alternative to overcome these limitations. The authors report on endovascular aortic repair in a patient with an asymptomatic infrarenal aortic aneurysm and renal insufficiency. The precise placement of the stent-graft was performed solely with contrast-enhanced US and intraprocedural angiographic fluoroscopy without the use of any nephrotoxic contrast media. At follow-up, contrast-enhanced US was used to exclude endoleaks and stent-graft failure or malposition.