Spinal cord ischemia after elective infrarenal aortic aneurysm repair is extremely rare, and documented cases that are described are of paraplegia. This case of tetraplegia occurred in a 64-year-old man with disabling claudication after an aortobifemoral graft repair for occlusive disease associated with a 5-cm infrarenal aneurysm. Magnetic resonance imaging supported lower cervical spinal cord ischemia, an unusual area for ischemia during aortic clamping since this area is usually most resistant. Because the lower thoracic and upper lumbar region, typically T8, is more susceptible to ischemia due to the variable collateral spinal cord circulation, the level of clamping was unlikely to be responsible. Other causes are considered. It was likely to be multifactorial and illustrates the need for great attention to detail in perioperative management and patient consent.