O’Brien et al. Journal of Medical Case Reports 2011, 5:401 http://www.jmedicalcasereports.com/content/5/1/401 ligament by dissecting instruments can injure the aorta, IVC or iliac vessels, depending on the level of the lami- nectomy [4]. Linton and White first reported such a case in 1945 [5]. Case reports also exist of fistulation following aortic aneurysm surgery and even after laparo- scopic appendectomy [6]. Post-traumatic AVFs may pre- sent many years after the initial injury, some reporting a traumatic history as distant as 30 to 52 years previously [7]. In such cases, the remote injury in combination with the diverse and subtle modes of presentation can result in delayed or overlooked diagnosis of the fistula. Typical symptoms include back pain (70%) and progres- sive sequelae from high output CCF (such as orthop- noea, edema and fatigue) [4]. An abdominal bruit is commonly demonstrable (80%). Our patient reported unilateral, progressive leg claudication, confirmed with unilaterally reduced ABI and toe pressure readings. This reflected a steal phenomenon which was subsequently fully reversed following exclusion of the AVF. To the best of our knowledge, this interesting phenomenon has not previously been described. Treatment of iliac AVFs in the open vascular surgical era was fraught with danger, with reported surgical mor- tality rates of 9-34%. Operative blood loss of six liters was common [8]. Acute presentations with spontaneous ruptures are thankfully rare (less than 4% of ruptured aneurysms [9]) but carry a significantly higher mortality rate. Conclusion The evolution of endovascular surgery has led to a para- digm shift in the approach to managing aneurysmal dis- ease with a concomitant vast reduction in mortality and morbidity rates. The first endovascular exclusion of an iliocaval fistula appeared in 1995 [10]. We add to the lit- erature this report of a successful endovascular exclu- sion of a giant, spontaneous, ilio-iliac AVF. Our case demonstrates several aspects of modern day vascular surgery such as the importance of preoperative imaging and planning, as well as the emerging role for a hybrid endovascular and open surgical approach to minimize operative morbidity as well as optimize long-term suc- cess for such complex vascular pathology. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Authors’ contributions GOB was the main author, treated our patient, researched the topic and coordinated the editing of the paper. CM & ZM were major contributors to researching, writing and editing the paper. NH, MPC, PM, DM & SON were Page 3 of 3 all involved in making treatment decisions regarding our patient as well as reading, making editorial suggestions and approving the final manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 5 January 2011 Accepted: 22 August 2011 Published: 22 August 2011 References 1. Sarmiento JM, Wisniewski PJ, Do NT, Vo TD, Aka PK, Tayyarah M, Hsu JH: Bifurcated endograft repair of ilio-iliac arteriovenous fistula secondary to lumbar diskectomy. Ann Vasc Surg 2010, 24(4):551e.13-7. 2. Wang G, Carpenter JP: The powerlink bifurcated system for endovascular aortic aneurysm repair: six-year results. J Vasc Surg 2008, 48:535-545. 3. Cronin B, Kane J, Lee W, Shriki J, Weaver FA: Repair of a high-flow iliac arteriovenous fistula using a thoracic endograft. J Vasc Surg 2009, 49:767-770. 4. Krishna M, Theodore S, Varma PK, Neelakandhan KS: Spontaneous iliac arteriovenous fistula: recognition and management. J Cardiovasc Surg 2005, 46:181-182. 5. Linton RR, White PD: Arteriovenous fistula between the right common iliac artery and inferior vena cava: report of a case following operation for a ruptured intervertebral disc. Arch Surg 1945, 50:6-13. 6. Keuhnl A, Zimmermann A, Pongratz J, Eckstein HH: Young girl presenting with heart failure 5 years post laparoscopic appendicectomy. Case report of an ilio-iliac AV fistula. Eur J Vasc Endovasc Surg 2010, 40(1):107-109. 7. Chaudry M, Finn WR, Kim K, Neschis DG: Traumatic arteriovenous fistula 52 years after injury. J Vasc Surg 2010, 51(5):1265-1267. 8. Brewster DC, Cambria RP, Moncure AC, Darling RC, LaMuraglia GM, Geller SC, Abbott WM: Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991, 13(2):253-264. 9. Bertinchant JP, Nigond J, Dauzat M, Ovtchinnikoff S, Noblet D, Arnaud E, Bengler C, Arich C, Lopez FM, Hertault J: Arteriovenous fistula caused by spontaneous rupture of an aortic or iliac aneurysm in the iliocaval venous system. Arch Mal Coeur Vaiss 1992, 85(1):91-94. 10. Zajko AB, Little AF, Steed DL, Curtiss EI: Endovascular stent graft repair of common iliac artery to inferior vena cava fistula. J Vasc Interv Radiol 1995, 6:803-806. doi:10.1186/1752-1947-5-401 Cite this article as: O’Brien et al.: Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report. Journal of Medical Case Reports 2011 5:401. 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