Extracranial carotid artery aneurysm is an extremely rare peripheral arterial aneurysm. The treatments of extracranial CAAs include open surgical, endovascular, and conservative options. Main surgical indications are transient ischemia attacks, strokes, or progressive growth. But both open surgery and endovascular repair have disadvantages and complications. We report a case of true internal carotid artery aneurysm (ICAA) with hostile anatomic conditions for both open surgery and endovascular approach in a 53-year-old man who presented with new cerebral infarctions. According to the features of this case, the patient was treated with a new hybrid procedure with extra-luminal aneurysm repair. A sheath was inserted through the common carotid artery, maneuvered out of the lumen through the proximal landing zone of the ICAA, and then returned into the distal normal vessel of the internal carotid artery. A stent graft was delivered through the sheath and was deployed while retrieving the sheath. The aneurysm was repaired successfully with an uneventful postoperative course and no postprocedural complications. The patient has been followed up for 2 years with no symptom, and the stent was patent without restenosis. The procedure is feasible and provides a new solution for difficult cases like this. Copyright © 2020 Elsevier Inc. All rights reserved.