Background: Primary aortocaval fistulas (ACF) are a rare complication of abdominal aortic aneurysm (AAA), for which treatment options encompass both endovascular and open surgical intervention. Purpose: To report a rare presentation of primary aortocaval fistula. Research Design: Case Report. Study Sample: Single Patient Case. Data Collection and/or Analysis: Single case report. Results: We present a 54-year-old male with a ruptured AAA and associated ACF uniquely located near the caval confluence which was managed through primary endovascular exclusion. Notably, we report significant migration of our graft upon deployment, due to high flow through the ACF. Following a literature review on ACFs, we remark on the anatomic challenges regarding management of an ACF. Conclusions: Awareness of the clinical signs and symptoms remains imperative in proper ACF management given its high mortality.
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