Venous gangrene secondary to an aorto-caval fistula.

W e report the unusual case of a 60-year-old-man presenting with left lower limb venous gangrene caused by an aorto-caval fistula. There was associated bilateral lower limb and scrotal oedema. In this case a ruptured aortic aneurysm with acute fistulation into the vena cava (fig 1) was repaired in the conventional manner. However, the patient underwent above-knee amputation of irreversible venous gangrene. Venous gangrene is typically caused by ilio-femoral thrombosis, whereas aortocaval fistulation is a rare occurrence with only 250 cases reported. The diagnosis of an aorto-caval fistula can be missed if meticulous examination of the abdomen is not done, especially for a pulsatile mass and a bruit which is associated with an aorto-caval fistula. We hope this case will help our colleagues to consider this diagnosis when a case of venous gangrene is encountered.