O’Brien et al. Journal of Medical Case Reports 2011, 5:401 http://www.jmedicalcasereports.com/content/5/1/401 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report Gavin C O’Brien*, Colm Murphy, Zenia Martin, Naseem Haider, Mary P Colgan, Dermot Moore, Prakash Madhavan and Sean M O’Neill Abstract Introduction: Spontaneous iliac arteriovenous fistulae are a rare clinical entity. Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury. Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac failure and the presence of an abdominal bruit. Diagnosis, therefore, is often incidental or delayed. Case presentation: We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure. Following computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni- iliac device) and open (femoro-femoral crossover) approach. Conclusion: Endovascular surgery has revolutionized the management of such fistulae and we report an interesting case of a high-output iliac arteriovenous fistulae successfully treated with a hybrid vascular approach. Introduction Spontaneous iliac arteriovenous fistulae (AVF) are a rare clinical entity. Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury [1]. Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac fail- ure (CCF) and the presence of an abdominal bruit. Diagnosis, therefore, is often incidental or delayed [2]. Case presentation A 68-year-old Caucasian man was referred to our out- patients clinic following the incidental discovery of a 6 × 8 cm distended iliac vessel whilst having an ultra- sound for surveillance of liver cirrhosis. His clinical his- tory revealed a progressive history of right flank pain, worsening right leg claudication and a persistently cold sensation in his right foot. He also complained of pro- gressive breathlessness on exertion, clinically suggestive of deteriorating CCF. There was no history of trauma or previous surgery. Ankle-brachial pressure measurements revealed a reduced index of 0.76 on the right, and a nor- mal index of 1.35 on the left with corresponding toe * Correspondence: gavinobrien@rcsi.ie St James’ Hospital Vascular Department, St James’ Hospital, Dublin 6, Ireland pressures of 55 mmHg and 143 mmHg respectively. A contrast enhanced computed tomography (CT) scan showed an isolated right common iliac artery (CIA) to right common iliac vein AVF (Figure 1). His aorta was normal in caliber, measuring 19 mm at the aortic bifur- cation. The aneurysmal segment began immediately dis- tal to the aortic bifurcation at the origin of the right CIA, with no normal segment of CIA evident. The aneurysm measured 9.4 cm in maximal diameter and extended to within 17 mm of the right iliac bifurcation. It was impossible to differentiate the arterial wall from the venous wall in the aneurysmal segment on either ultrasound or CT scans. His inferior vena cava (IVC) was grossly distended with a uniform diameter of 36 mm in its full course. Pre-operative discussions focused on finding an endo- vascular strategy to solve the problem. As no normal caliber proximal right CIA existed, an isolated iliac cov- ered stent was impossible as no proximal sealing zone existed. This required sealing a proximal stent in his aorta. Bifurcated endografts have been used to seal ilio- iliac fistulae previously [1]. The aortic bifurcation dia- meter was 19 mm in this case and although some devices have reported success negotiating smaller aortic bifurcations [2], we felt an aorto-bi-iliac graft would be © 2011 O’Brien et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.