Isolated aneurysms of the internal iliac (hypogastric) artery are a rare variant of aorto-iliac aneurysm disease, with an incidence at around 0.04% of all aorto-iliac aneurysms. Because of their location deep within the pelvis, they may present late and are often large. The incidence of rupture is high and may be up to 38% at initial presentation; furthermore, this has been reported to carry a 58% mortality rate. As such the early and aggressive management of isolated internal iliac artery aneurysms (IIAAs) is mandatory to avoid the high morbidity and mortality associated with rupture. This article includes a literature review regarding IIAAs and outlines the current surgical and endovascular management options for this most rare and technically challenging of aneurysms.