Aortocaval fistula is a rare entity and may occur with either aneurysmal or non-aneurysmal aortae; most fistulae are detected during the course of preoperative workup for aortic aneurysms but can be encountered unexpectedly during open repair. The natural history of an aortocaval fistula is progressive congestive heart failure leading to death, and therefore, the fistula and an associated aneurysm should be repaired as soon as feasible. Traditional open surgical repair is effective and durable, but associated with perioperative morbidity such as blood loss, suggesting the possibility of improved results with endovascular repair. However, endoleaks may be associated with fistula recurrence, suggesting the need for vigilant surveillance and longer-term studies. Hybrid repairs, such as endovascular venous control of the fistula during open repair, may be another attractive option.