Rupture of the major veins is a rare complication of abdominal aortic aneurysms and is generally followed by sudden haemodynamic changes, whose importance is strictly dependent on the size of the fistula and rapidity of onset. The final result is invariably hyperdynamic congestive heart failure, oligoanuria and hyperazotemia, expression of renal insufficiency. Early recognition and surgical operation, together with appropriate postoperative intensive care, are the key for successful treatment of aorto-caval fistulas. Despite the improvement of surgical and anaesthesiology techniques, operative mortality rate still remains elevated (36%), but not higher than in other abdominal aortic aneurysms ruptures. The aim of this paper is to review the literature and to report one case of a seventy-year-old patient affected by an aorto-caval fistula and successfully treated in our Surgery Division.