Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm, which erodes into the wall of the inferior vena cava, resulting in the formation of a fistula. ACF presents with various inconsistent symptoms and signs. ACF can be a diagnostic dilemma if not suspected and it is lethal if left untreated.A 60-year-old man presented with abdominal and lower back pain of sudden onset. Renal and liver functions were impaired, without signs of cardiac failure. CT angiography revealed an abdominal aneurysm rupture into the inferior vena cava. Patient underwent a successful open repair: ACF ligation from within the aneurysmal sac and an aorto-bi-iliac bypass using a Dacron graft. Renal and liver functions improved and the patient was discharged on the eighth postoperative day. A month later, the patient was fit and well with normal liver and renal functions.Despite progress made in the endovascular treatment of ACF, complications still persist with a reported endoleak rate of 50%. Open repair is still a valid method for ACF repair in patients fit to undergo laparotomy and general anaesthesia. In this case, the patient was fit and along the lack of a suitable stent graft, the vascular team performed an open repair with good results.Open repair of an ACF is a valid treatment method for patients who are fit enough to undergo laparotomy and general anaesthesia, and avoids complications related to endovascular repair, such as endoleaks.