Yuminaga et al. Journal of Medical Case Reports 2012, 6:33 http://www.jmedicalcasereports.com/content/6/1/33 Page 3 of 6 Figure 2 Arch aortogram demonstrating the right-sided central venous catheter entry site into his right common carotid artery and the tip in his innominate artery. demonstrated a persistent fistula. The balloon was re- inflated for five minutes. Subsequent angiography revealed a widely patent carotid artery with no AV fis- tula or contrast extravasation visible (Figure 4). Our patient remained hemodynamically unstable dur- ing surgery and, in consultation with cardiologists, the anesthetists asked that an urgent repair of the iliocaval fistula be considered during the same operation. A calibrated aortogram was performed and bilateral Abbott Perclose devices (Abbott Park) were deployed. A 24 mm×96 mm Cook Zenith bifurcated stent graft (Bloomington) was introduced via the left iliac system. Access to his abdominal aorta was also obtained via his right femoral artery. We placed a 12 mm×107 mm Tri- Fab Limb Extension endograft limb landing in the right external iliac artery distal to the aneurysm and iliocaval fistula. Consideration was given to coil embolization of his right internal iliac artery prior to this but it was felt not to be necessary due to the anatomy at the iliac bifurcation. A 12 mm×56 mm endograft limb was placed on the ipsilateral left side and landed in the distal left common iliac artery. There was an immediate reduction in our patient’s measured central venous pres- sure and a classical venous waveform returned. Comple- tion angiography demonstrated a small amount of late filling of the common iliac aneurysm via a type two endoleak but no iliocaval fistula. It was felt that, on cor- rection of his coagulopathy, this would allow for throm- bosis of the aneurysmal sac. Wires and sheaths were removed and the Perclose devices used to seal the femoral puncture sites with good effect. Our patient received four units of fresh frozen plasma, one unit of pooled platelet and eight units of cryoprecipitate. Figure 3 Selective right carotid angiogram after removal of the central venous catheter, demonstrating contrast extravasation in his neck and opacification into his internal jugular vein. By postoperative day three, our patient’s acidosis was corrected and his biochemistry and hematology para- meters had improved: his Cr was 116 μmol/L, GGT was 135 IU/L, bilirubin level was 30 μmol/L, AST was 552 IU/L, Hb was 84 g/L, platelet count was 55 × 109/L and INR was 1.37. His central venous pressure was normal- ized to 15 mmHg. He was making an adequate amount of urine and CVVHDF was ceased. Our patient was extubated successfully and a CT angiogram demon- strated a successful endovascular repair with patent endografts and no evidence of endoleak or AV fistula. Our patient was transferred back to his regional hospital after a satisfactory progress CT angiogram (Figure 5) and was discharged home three weeks later. At six-week follow-up there remained no evidence of endoleak on a progress CT angiogram (Figure 6). Discussion An iliocaval fistula is a rare complication of an iliac artery aneurysm. It is an abnormal communication between the iliac artery and the IVC. The etiology can be spontaneous rupture, trauma, post-aneurysm repair or iatrogenic injury following lumbar surgery [2,3]. The