Yuminaga et al. Journal of Medical Case Reports 2012, 6:33 http://www.jmedicalcasereports.com/content/6/1/33 hypercholesterolemia and excessive alcohol consumption (more than 80 g per day). His usual medications were atenolol, felodipine, aspirin and naproxen. Laboratory studies conducted at the regional hospital showed a creatinine (Cr) level of 269 μmol/L (normal range: 60 μmol/L to 110 μmol/L), aspartate transami- nase (AST) of 2309 IU/L (normal range: 8 IU/L to 40 IU/L), alanine transaminase of 1994 IU/L (normal range: 5 IU/L to 60 IU/L), gamma-glutamyltransferase (GGT) of 177 IU/L (normal range: 40 IU/L to 78 IU/L), biliru- bin of 33 μmol/L (normal range: 3 μmol/L to 18 μmol/ L), white cell count of 27.8 × 109/L (normal range: 4 × 109/L to 11 × 109/L) hemoglobin (Hb) of 120 g/L(nor- mal range: 135 g/L to 180 g/L), an international normal- ized ratio (INR) of 2.4 and platelet count of 50 × 109/L (normal range: 150 × 109/L to 400 × 109/L). Metabolic acidosis was also noted. A provisional diagnosis of multiorgan failure due to septic shock was made. Empirical intravenous antibiotics (cefotaxime) were started. A central venous cathether was sited in his right internal jugular vein under ultra- sound guidance. Following this, however, he experienced a transient ischemic attack with left-sided weakness last- ing five minutes. A duplex ultrasound of his right neck was performed, demonstrating the presence of the cen- tral venous catheter (CVC) passing through his right internal jugular vein posteriorly into the lumen of his right CCA. He was subsequently referred to the Vascu- lar Surgery Service at our tertiary hospital for further management. On admission to our hospital, our patient had a heart rate of 89 beats per minute (atrial fibrillation), blood pressure of 156/56 mmHg and oxygen saturation of 98%. He had mild bilateral leg edema, a palpable liver edge and a raised jugular venous pressure. No pulsatile mass was identified. In our Intensive Care Unit, a diagnosis of heart failure was made in association with a central venous pressure of 35 mmHg. An incidental right common iliac aneur- ysm of 6.4 cm×6.2 cm had been detected on non-con- trast computer tomography (CT) of his abdomen and pelvis at the referring hospital. An iliocaval fistula was not suspected at that time. He was started on continu- ous venovenous hemodiafiltration (CVVHDF) for anuric acute renal failure and fluid overload. Clinical and laboratory evidence of disseminated intravascular coagu- lation led to the commencement of Vitamin K and fresh frozen plasma. An operative endovascular approach was planned in light of our patient’s multiple acute comorbidities. Our patient consented to the removal of the central line with carotid angiography and endovascular balloon inflation to aid hemostasis. Page 2 of 6 Intra-operatively, with our patient in the supine posi- tion and under general anesthesia, his right common femoral artery was punctured in a retrograde manner using the standard Seldinger technique. A 5 French sheath was inserted and an attempt made at passing a 0.035 Glidewire into his abdominal aorta. The wire was noted to pass up well to the right of the midline consis- tent with the anatomical position of the inferior vena cava (IVC). Contrast angiography via the right femoral sheath demonstrated opacification of the right common iliac artery aneurysm as well as the IVC. It was noted that the pressure and waveform from the left internal jugular CVC displayed a mixture of arterial and venous patterns. An intra-operative diagnosis of an iliocaval fis- tula was made. A left common femoral artery sheath was then placed and access to his abdominal aorta was achieved. An aor- togram then demonstrated the large right common iliac artery aneurysm and associated iliocaval fistula (Figure 1). Access into his right CCA was then achieved with a Cook Shuttle sheath (Bloomington, IN, USA). Carotid angiography demonstrated the catheter entry point into his mid-right CCA (Figure 2). The catheter was removed and angiography revealed a carotid-to-jugular arteriove- nous (AV) fistula (Figure 3). An 8 mm×40 mm Abbott FoxCross (Abbott Park, IL, USA) angioplasty balloon was positioned distal to the carotid bifurcation and inflated for three minutes. Angiography then Figure 1 Aortogram demonstrating a large right common iliac artery aneurysm with simultaneous contrast opacification of his inferior vena cava.