Complex endovascular repair of complicated abdominal aortic aneurysm due to aortocaval fistula

Aortocaval fistula is a rare but life-threatening complication of abdominal aortic aneurysm. We report the case of a 63-year-old man who was found to have hyperdynamic heart failure caused by a large infrarenal abdominal aortic aneurysm fistulized to the inferior vena cava. An urgent endovascular approach was performed using an aortomonoiliac endoprosthesis with femorofemoral bypass and adjunctive iliac stenting. Despite initial clinical improvement, follow-up imaging revealed a persistent endoleak maintaining patency of the fistula. A secondary endovascular procedure was successfully performed, including hypogastric artery embolization and placement of a cava endoprosthesis to exclude the fistulous communication. Follow-up computed tomography angiography at 6 months confirmed complete exclusion of the aneurysm and resolution of the aortocaval fistula without endoleaks.