O’Brien et al. Journal of Medical Case Reports 2011, 5:401 http://www.jmedicalcasereports.com/content/5/1/401 Page 2 of 3 Figure 1 Preoperative CT. Preoperative contrast-enhanced CT 3-D reconstruction with arrow demonstrating the 8 cm ilio-iliac AV fistula originating from the proximal right CIA. in danger of being compressed at the bifurcation with a high risk of occlusion. As a result, a hybrid approach with deployment of an aorto-uni-iliac (AUI) device fol- lowed by a femoro-femoral bypass was planned. Our patient was operated upon in our endovascular suite (Siemens) under spinal anesthesia. Both common femoral arteries (CFA) were controlled and cannulated with 6Fr sheaths (Johnston & Johnston). His aorta was cannulated with a 0.035 wire Bentson wire (Cook Medi- cal, Bloomington, IN, USA) via each CFA with the assis- tance of an angled catheter (Kumpe, Cook Medical). A diagnostic flush pigtail catheter was placed in his aorta via the contralateral limb. A stiff 0.035 Amplatz wire (Amplatz Super Stiff, Boston Scientific) was exchanged as access to the ipsilateral limb. Following an angiogram to confirm renal anatomy, an aorto-uni-iliac device (Zenith Renu, Cook Medical) was deployed from imme- diately below his renal arteries to his mid right external iliac artery, thus occluding his right internal iliac artery. A 14 × 10 mm Amplatzer occlusion device (AGA Medi- cal Corp, MN, USA) was deployed via the contralateral limb to his proximal left CIA. A completion angiogram confirmed exclusion of the ilio-iliac AVF. A right to left femoro-femoral bypass with 8 mm polytetrafluoroethy- lene (PTFE) was performed to re-establish flow to his left leg as well as providing left internal iliac perfusion. On the first postoperative day, the mass was no longer pulsatile and the machinery-like murmur in the right iliac fossa was absent. A CT scan on postoperative day two confirmed a patent AUI endovascular graft and patent femoro-femoral bypass, as well as confirming exclusion of contrast from the right iliocaval system (Figure 2). His right foot no longer felt cool and the postoperative ankle brachial index (ABI) confirmed an index of 1.05 on the right and 0.95 on the left, with cor- responding toe pressures of 119 mmHg and 117 mmHg respectively. He was discharged after seven days without complication. At a clinic one month later, his claudica- tion had resolved completely and he no longer had symptoms suggestive of CCF. A duplex ultrasound con- firmed exclusion of arterial flow from the iliocaval vessels. Discussion Penetrating traumatic injury remains the most common cause of abdominal and pelvic arteriovenous fistulae [3]. This trauma may be malicious but is frequently iatro- genic, commonly occurring after lumbosacral laminect- omy whereupon penetration of the anterior longitudinal Figure 2 Postoperative CT. Postoperative CT 3-D reconstruction showing endovascular exclusion of the AV fistula with an aorto-uni- iliac graft (white arrow) and a functioning right to left femoro- femoral cross-over bypass (red arrow).