Aneurysm repair in the presence of a horseshoe kidney presents a rare and technically demanding challenge, particularly in regional practice where exposure to this anatomy is limited. Horseshoe kidneys are frequently associated with aberrant renal arterial supply and operative planning can be difficult when the renal isthmus and multiple accessory arteries are closely related to the aneurysm. A 65-year-old man with a 7 cm right common iliac artery aneurysm and a centrally positioned horseshoe kidney underwent CTA, which demonstrated an extensive branching pattern with multiple renal arteries arising from the abdominal aorta and iliac vessels. The horseshoe kidney was draped over the iliac aneurysm, creating substantial anatomical complexity. 3-D volumetric modelling and 3-D printing were used to improve spatial understanding of the renal isthmus, accessory renal arteries, aneurysm morphology and operative exposure. The 3-D printed model also facilitated the consent process by helping the patient better understand the anatomy. An endovascular solution was considered undesirable because of the risk of compromising accessory renal arteries and the complexity of achieving durable iliac exclusion without sacrificing important renal perfusion. Open repair was therefore performed. The horseshoe kidney was carefully mobilised, accessory renal arteries were preserved, and the aneurysm was repaired with a Dacron graft anastomosed between the right common iliac artery and the iliac bifurcation. This case highlights the value of 3-D printing in regional aneurysm practice, particularly when managing rare anatomy that may be unfamiliar to the treating team. In selected patients with horseshoe kidney and complex aberrant renal arterial anatomy, open surgical repair remains an important and sometimes preferable option when endovascular exclusion risks renal ischaemia or inadequate aneurysm treatment.