In compliance with SCARE criteria (Agha et al.), this report is a case of a 26-year-old African female, who presented with massive haemoptysis, chest pain and persistent cough. The patient had been treated for pulmonary TB two years before and had Human Immunodeficiency Virus, which was being treated with antiretroviral drugs. The patient was acute-on-chronic ill looking and clinically wasted. She had mild respiratory distress with respiratory rate of 22 breaths per minute. Other vital signs were normal. Physical examination revealed pale sclera and palms, which were suggestive of anaemia. On chest examination, there were crepitations on the left upper lobe area with no murmurs audible to suggest the presence of the fistula. The baseline blood confirmed anaemia with haemoglobin of 5.1 g/dl and other bloodlines were normal. An International normalized ratio (INR), urea, electrolytes and creatinine were also normal. Resuscitation was undertaken while completing other investigations. Chest X-ray (CXR) was done, with posteroanterior (PA) and lateral views showing left upper zone opacification obscuring the left cardiac knob [Fig. 1A,B]. The left lower zone had an opacity obscuring the left cardiac border, suggestive of multilobar infection/vascular pathology. In subsequent computed tomography angiogram (CTA), there was a reverse "S" shaped outpouching contrast content structure from aortic arch lateral to the Left Subclavian Artery (LSA) origin with adjacent pleural density and surrounding the lung opacity. The features were suggestive of aneurysm, which complicated with aortobronchial fistula surrounded by haematoma [Fig. 2A-C]. The lingula segment of the left upper lobe had consolidative changes and there were also bilateral diffuse patchy scattering centrilobar opacities, which suggested an active pulmonary infection [Fig. 3A,B]. The patient was admitted to Intensive Care Unit (ICU) for optimization in preparation for surgery. Medical therapy in the form of antitussive, sedatives, antifibrinolytics and empirical antibiotics were provided. The patient did not require any security of the airway or mechanical ventilatory support. The patient underwent TEVAR two days after ICU admission. The procedure was done via general anaesthesia with invasive lines monitoring. The right femoral artery was exposed via oblique groin incision. The left common femoral artery was punctured with 5Fr sheath for angiographic access. The initial angiogram showed that the Left Common Carotid Artery (LCCA) had a common origin with brachiocephalic trunk [Fig. 4A]. At approximately 10 mm distal to the LSA, a focal aneurysm was noted on the proximal descending aorta, with 13 mm base. The appearance suggested a vascular aneurysm (Fig. 4A). There was no opacification of the pulmonary vasculature. Through the brachial artery approach, a vascular occlusion plug (Amplatzer) was deployed to the origin of the LSA to minimize the risk of the endoleaks. The TEVAR was performed via the right groin access, using Medtronic navion thoracic stentgraft with coverage of the LSA [Fig. 4B]. The completion angiography showed appropriate opacification of brachiocephalic trunk and its branches, including the LCCA. There was no flow into LSA. Fistula and aneurysm were excluded. Postoperative phase was uneventful. Within the same admission (after two weeks) the patient was taken for second stage of the operation, which involved apical-lower segmentectomy and apace-posterior segment debridement and pulmonary fistula repair. The approach was via muscle sparing posterolateral thoracotomy with the chest entered through the 5th intercostal space, over unresected 6th rib. Intra-pleural mobilization of the lung was undertaken with the use of both blunt and sharp dissections. A haematoma was identified within apical-lower segment. The apical part of apico-posterior segment was attached to the aorta at the fistula site, which on mobilization the two were separated without bleeding [Fig. 5]. The fistulae site on both aorta and lung were biopsied for microbiological and histopathological studies. An oblique fissure was complete, with less dense adhesions, for which adhesionolysis was done. The interlobar artery was identified and its overlying pleura was opened and dissected. The apical lower segment artery was identified, dissected, suture ligated and divided. The vein draining the apical-lower segment was also dissected and controlled in similar manner. The bronchus to apical lower segment was dissected and clamped, and an anaesthetist was asked to insufflate the lung for delineation of segment. The GIA stapler was used to resect apical lower segment bronchus. The stump was immersed into saline and was not leaking. The apical part of apico-posterior segment adjacent to area of the fistula was necrotic. It was debrided and closed with continuous Prolene 4/0 suture without using a healthy or pleural tissue for buttressing, because the tract was too small and was thoroughly debrided. A tissue of the fistula stump on the aorta was sampled for microbiological and histopathological studies. The aortic fistula stump was approximated with interrupted Prolene 4/0 suture. A size 7.5 rigid bronchoscope was passed into the airway, the trachea and the carina looked normal. No fistula was visualized within airway. The operation was uneventful and the patient was discharged and reviewed after two weeks for general follow up and histopathology results. Hematoxylin and Eosin (H&E) sections [Fig. 6A,B] showed fibrous connective tissue with poorly formed granulomas while lung sections showed necrotizing granulomatous inflammation. The granulomas were composed of aggregates of epitheliod histiocytes with central caseating necrosis and Langhan-type giant cells. Acid-fast fast bacilli or fungi were not evident. Although acid-fast bacilli were not identified [Fig. 5C,D], mycobacterial infection was still favoured. Correlation with microbiological culture and susceptibility testing was advised. The patient was put on anti-tuberculous treatment for nine months, which she completed uneventfully. She is currently coming for follow-ups every three months to check for possible recurrence.