Chronic aortocaval fistula (ACP) is a rare complication of penetrating trauma to the abdomen. We report a case of traumatic ACP presenting with pulmonary hypertension and right heart failure symptoms 15 years after the initial penetrating injury. Although symptoms of pulmonary hypertension started 5 years ago, it was wrongly diagnosed and treated as chronic obstructive pulmonary disease. The presence of a continuous abdominal bruit and history of penetrating abdominal trauma gave rise to suspicion of a fistula, which was confirmed by computed tomography and angiography. Percutaneous closure of ACP was planned, but the patient died of severe pneumonia. The clinical presentation of chronic ACP can vary from being asymptomatic to symptoms related to pulmonary hypertension, right heart failure, and pulmonary embolism; thus, definitive diagnosis can be challenging.