Yuminaga et al. Journal of Medical Case Reports 2012, 6:33 http://www.jmedicalcasereports.com/content/6/1/33 Page 5 of 6 Figure 6 Maximum intensity projection reconstruction of a postoperative computed tomography angiogram, demonstrating thrombus in the right common iliac artery aneurysm sac with no evidence of endoleak and retrograde filling of the right internal iliac artery stump. for such an ill patient. Schepers et al. [7] employed endovascular coiling as first line treatment due to their patient’s condition. Prompt diagnosis with an appropriate investigation is important in such a disease with diverse presentation. Aortic angiography used to be the investigation of choice to confirm the clinical suspicion of aortocaval or iliocaval fistula [10]. For the past two decades, CT with intravenous contrast has been used more frequently for the diagnosis of aortocaval or iliocaval fistula [8,11]. Important radiological diagnostic features include aortic or iliac artery dilatation, vena caval dilatation, increased density of the IVC similar to that of the aorta and visua- lization of the fistula [11]. Traditionally, fistulas associated with aortic aneurysm have been treated with open surgery [5]. However, this has been associated with high rates of morbidity and mortality, although mortality has decreased from 50% (Baker et al. [2]) to 20% (Brewster et al. [5]). Over 20 years, major morbidity has remained high. Disadvan- tages of open repair have included large intra-operative blood loss (mean blood loss of 4,500 mL (range 3000 mL to 8000 mL) [12] in reported cases of open repair), high intensive care unit admissions and long lengths of hospital stay. Twenty-three cases of endovascular repair of major abdominal AV fistula in the literature were reviewed, and endovascular repair had a high reported success rate of 96%, with one patient requiring open conversion, and 100% survival at a mean follow-up of nine months [1]. This case involving a patient with mul- tiorgan failure demonstrates successful intra-operative adaptation and the immediate hemodynamic benefit possible with major AV fistula repair with no major complications. Conclusion Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an ilio- caval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Unusual iatrogenic causes of iliocaval fistula secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours. Consent Written informed consent was obtained from the patient for publication of this manuscript and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Acknowledgements The authors would like to acknowledge the patient in this case. No funding was provided for this case report. Authors’ contributions YY made substantial contributions to this article in the design, literature review and write up. WM was involved in drafting the script and revising it critically. AT made a substantial contribution in acquiring the data of the patient and revising the article critically. TN made a substantial contribution in reviewing the patient’s data. CF gave final approval of the version to be published. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 24 June 2011 Accepted: 24 January 2012 Published: 24 January 2012 References 1. Antoniou GA, Koutsias S, Karathanos C, Sfyroeras GS, Vretzakis G, Giannoukas AD: Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009, 16(4):514-523. 2. Baker WH, Sharzer LA, Ehrenhaft JL: Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 1972, 72(6):933-938. 3. Lanne T, Bergqvist D: Aortocaval fistulas associated with ruptured abdominal aortic aneurysms. Eur J Surg 1992, 158(9):457-465. 4. Rajmohan B: Spontaneous aortocaval fistula. J Postgrad Med 2002, 48(3):203-205. 5. 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, discussion 64- 65. 6. Gregoric ID, Jacobs MJ, Reul GJ, Rochelle DG: Spontaneous common iliac arteriovenous fistula manifested by acute renal failure: a case report. J Vasc Surg 1991, 14(1):92-97.