Treatment of a ruptured aorto-iliac aneurysm with right iliac arteriovenous fistula: Surgical considerations in the endovascular era

Objective: Rupture of abdominal aortic aneurysms (AAA) into the iliac or caval veins through arteriovenous fistulas (AVFs) is a rare but life-threatening complication. We report a case of a 74-year-old man with complex aorto-iliac aneurysmal disease and a spontaneous right iliac AVF, presenting with worsening dyspnea and signs of congestive heart failure. Case presentation: A 74-year-old man with complex aorto-iliac aneurysmal disease and a spontaneous right iliac AVF, presented with worsening dyspnea and signs of congestive heart failure. Imaging revealed a 45 mm infrarenal AAA, a 50 mm right common iliac artery aneurysm, and an 87 mm right external iliac artery aneurysm. The anatomical configuration—including a short, angulated proximal neck and severely tortuous iliac arteries—rendered the patient unsuitable for endovascular repair. Therefore, an emergent open surgical repair was performed, consisting of aneurysmectomy, AVF closure, and aorto-bi-iliac reconstruction using a Dacron graft. Postoperative recovery was uneventful, with improvement in cardiac and renal function. Conclusion: This case highlights the ongoing relevance of open surgical approaches in an era dominated by endovascular techniques, particularly when anatomical or hemodynamic challenges limit the feasibility of minimally invasive options.