Aortoduodenal fistula: A case report and review of literature

Abstract

BACKGROUND

Aortoduodenal fistula (ADF) is a rare, often catastrophic condition characterized by an abnormal communication between the abdominal aorta, or an aortic graft, and the duodenum. Although infrequently encountered, ADF is associated with massive gastrointestinal hemorrhage and high mortality if not promptly recognized and treated. This manuscript summarizes the epidemiology, pathogenesis, clinical manifestations, diagnostic modalities, management strategies, particularly in techniques for repairing the duodenum, and outcomes of ADF.

CASE SUMMARY

We present a case report of a 79-year-old male with a history of an open repair for a ruptured abdominal aortic aneurysm, complicated by an ADF. He was successfully treated with in-situ aortic reconstruction using a bovine pericardial graft, followed by a Roux-en-Y duodenojejunostomy. The postoperative recovery was uneventful. A review of current literature shows that primary two-layer duodenorrhaphy with omental interposition remains the most commonly reported approach for small, viable defects. For larger or complex injuries, reinforcement with a jejunal serosal patch or vascularized tissue flaps provides additional protection. Roux-en-Y duodenojejunostomy offers durable reconstruction in extensive duodenal involvement. Pyloric exclusion and other diversionary techniques have shown limited benefit and are now reserved for selected cases.

CONCLUSION

Optimal management of ADF requires an individualized strategy for duodenal repair in conjunction with definitive aortic reconstruction and infection control. While current evidence supports tailoring the repair technique to defect size and tissue quality, prospective data are lacking. Multicenter reporting is essential for establishing evidence-based guidelines.

Key Words: Aortoenteric fistula; Aortoduodenal fistula; Secondary; Endovascular; Duodenal repair; Case report

Core Tip: Aortoduodenal fistula is a rare but life-threatening cause of gastrointestinal bleeding requiring urgent surgical intervention. Management requires definitive aortic repair combined with tailored duodenal reconstruction. Small, viable defects are typically treated with primary repair and omental coverage, whereas larger or complex injuries may necessitate jejunal serosal patching, vascularized flaps, or Roux-en-Y duodenojejunostomy. Pyloric exclusion is reserved for selected cases. An individualized approach based on defect size and tissue viability is essential. We report a 79-year-old man with prior open abdominal aortic aneurysm repair who developed an aortoduodenal fistula and was successfully treated with bovine graft reconstruction and Roux-en-Y duodenojejunostomy.

INTRODUCTION

Vascular-enteric fistulas are among the most serious complications associated with aortic disease, with aortoduodenal fistula (ADF) being the most common type. First described by Sir Astley Cooper in the early nineteenth century[1], this condition remains rare but can lead to a devastating prognosis if not recognized. The duodenum, especially its third and fourth portions, is located directly in front of the abdominal aorta, making it susceptible to erosion from aneurysms or prosthetic grafts. The clinical significance of ADF lies in its potential to cause life-threatening gastrointestinal bleeding, which is often preceded by minor or nonspecific symptoms. Although advances in imaging, surgical techniques, and endovascular therapy have improved patient outcomes, they have not completely mitigated the high mortality rate associated with this condition[2,3].

An ADF is an abnormal connection between the lumen of the aorta and the lumen of the duodenum, either from the native vessel or a graft. Two major categories exist. Primary ADF: A primary ADF occurs spontaneously, without prior aortic surgery. The most common cause of this condition is the erosion of an untreated abdominal aortic aneurysm into the duodenum. Other rare causes include mycotic aneurysms, traumatic injuries, penetrating ulcers, and malignant invasion. Primary ADFs are extremely rare, with an estimated incidence of less than 0.1% among patients with abdominal aortic aneurysms[4-6]. Secondary ADF (SADF): A SADF occurs as a complication of aortic reconstructive surgery, typically open repair with prosthetic graft placement. The incidence of SADF ranges from 0.3% to 2% of patients after open abdominal aortic aneurysm repair. SADF usually occurs months to years after the initial operation, although cases have been reported within days or decades later[7,8].

Aortoenteric fistulas can involve the jejunum, ileum, or colon, but the duodenum accounts for 80%-90% of cases due to its anatomic proximity[9]. Primary ADF occurs in about 0.04%-0.07% of untreated abdominal aortic aneurysm patients. SADF is more common, especially with older prosthetic grafts. Most patients are male and over 60 years old, reflecting typical demographics for abdominal aortic aneurysm disease. Mortality rates are high, ranging from 30% to 50% with treatment and over 80% if untreated[10].

The development of SADFs is mainly influenced by mechanical erosion due to graft contact/pressure on adjacent bowel and prosthetic graft infection, causing erosion/necrosis. Endovascular aortic repair (EVAR)-related SADF may arise from stent migration, endoleak-related sac expansion, or infection[11,12]. ADF usually presents with gastrointestinal bleeding, including hematemesis, melena, hematochezia, or unexplained anemia. In up to 70% of cases, a sentinel bleed - a small, self-limited hemorrhage - precedes a massive, life-threatening bleed. Massive hemorrhage can lead to hypotension, tachycardia, altered mental status, and shock. Without prompt medical intervention, mortality rates can approach nearly 100%[13-16].

Diagnostic testing: Endoscopy is often performed first, but it can be non-diagnostic. Classic findings (visible graft, ulceration, or active bleeding) are uncommon. Sensitivity is limited (30%-40%) because most fistulae are beyond the visualized proximal duodenum, or intermittent bleeding is missed. Computed tomography angiography (CTA) is the imaging modality of choice. CTA may show graft-bowel contact, periaortic gas/fluid, irregularity around the graft, or contrast extravasation when bleeding is active, but CTA may be negative at the time of scanning. CTA has sensitivity up to 94% and specificity around 85% and is essential for surgical planning[17]. Despite multiple reports on ADF repair, the literature remains limited by small case series and heterogeneous treatment approaches. Although significant advances have been made in diagnosis and surgical management, mortality remains high, highlighting the need for an updated assessment of contemporary management strategies. This article aims to present a detailed case report of ADF, review the current literature on surgical management strategies for duodenal repair, and propose an algorithm to guide clinicians in the treatment of this rare and life-threatening condition.

CASE PRESENTATION

Chief complaints

A 79-year-old man presented with melena and symptomatic anemia.

History of present illness

The patient reported recurrent episodes of melena over the preceding three months, requiring multiple hospitalizations. Despite repeated evaluations - including upper gastrointestinal endoscopy, capsule endoscopy, and colonoscopy - no bleeding source had been identified. On this admission to Attikon University Hospital, he again presented with melena and worsening anemia. CTA revealed a 5.2 cm infrarenal saccular aneurysm with eccentric thrombus and close contact between the prior aortic graft and the third-fourth portions of the duodenum, raising strong suspicion for an SADF.

History of past illness

Twelve years earlier, the patient had undergone open repair of a ruptured infrarenal abdominal aortic aneurysm using a synthetic graft. He also had a history of myocardial infarction treated with percutaneous coronary intervention in 2022. He had independently discontinued dual antiplatelet therapy.

Personal and family history

No relevant personal habits or family history of vascular or gastrointestinal disease was reported.

Physical examination

Vital signs were stable. Abdominal examination revealed no tenderness, masses, or peritoneal signs. Digital rectal examination was positive for melena.

Laboratory examinations

Blood tests demonstrated hemoglobin of 7 g/dL, consistent with significant anemia. Other laboratory values, including biochemical profile and infection markers, were unremarkable.

Imaging examinations

CTA demonstrated a 5.2 cm infrarenal saccular aneurysm with eccentric thrombus, and a 2.5 cm left common iliac artery aneurysm. The aortic graft was in close contact with the third and fourth portions of the duodenum, but no active contrast extravasation was detected.

FINAL DIAGNOSIS

Given the patient’s history and imaging findings, a SADF was strongly suspected.

TREATMENT

In February 2024, the patient underwent open surgical repair. The infected synthetic graft was explanted, and a bovine pericardial graft was used for in-situ aortic reconstruction. A large contained ADF was identified, with local tissue quality that precluded primary repair. Thus, the third and fourth portions of the duodenum were resected, and a duodenojejunostomy was performed (Figure 1).

Figure 1 Duodenojejunostomy includes the creation of an end or side duodenojejunostomy to bypass the damaged segment (often the 3^rd/4^th portion). A: Duodenojejunostomy after resection of the third and fourth portions of the duodenum; B: Duodenojejunostomy with pyloric exclusion and Roux-en-Y gastrojejunostomy, after resection of the third and fourth portions of the duodenum; C: Duodenojejunostomy + pyloric exclusion with Billroth II gastrojejunostomy, after resection of the third and fourth portions of the duodenum.

OUTCOME AND FOLLOW-UP

Postoperative recovery was uneventful, and the patient was discharged in stable condition. At follow-up, the patient was recovering well with no complications. Eighteen months postoperatively, the patient is in good health.

DISCUSSION

A literature review was conducted using PubMed and PMC to identify studies relevant to ADF. Case reports, case series, and observational studies reporting secondary AEF after aortic reconstructive surgery (open aortic repair or EVAR) that were published between 2000 and September 2025 were included. Reference lists of relevant articles were also reviewed to identify additional eligible studies. Studies focusing on primary aortoenteric fistulae, experimental models, or non-human subjects were excluded. The literature consists primarily of single-centre case series and many case reports reporting atypical presentations, recurrent fistulae, or SAEF after EVAR. Table 1 summarizes the main studies found in the literature regarding ADF repair, with a focus on the techniques used for duodenal reconstruction[18-42].

Table 1 Summary of studies on aortoduodenal fistula repair focusing on duodenal repair techniques and outcomes (2000-2025).

Ref.	Study design, patient characteristics	Surgical technique	Outcomes
Jung et al[18], 2025	Single-center retrospective, n = 15	Primary repair (n = 8) vs duodeno-jejunostomy (n = 7)	The median duration of hospital stay was 32.7 days. 3 patients died after surgery; 11 patients survived until the last follow-up; leak in 3 (1 duodenal stump leakage, 2 died)
Piñerúa-Gonsálvez et al[19], 2025	Case report, M, 69	Duodeno-jejunostomy	Uneventful post- operative recovery
Sakakibara et al[20], 2024	Case report, F, 76	Duodeno-jejunostomy and Braun anastomosis	No recurrence after 16 months
Koliakos et al[21], 2023	Systematic review, n = 189	Primary bowel repair in 145 pts (76.7%), duodenectomy in 25 (13.2%), and no bowel repair in 19 (10.1%); additional omentoplasty in 65 pts (34.6%)	Mortality was comparable in any type of bowel repair (28% after duodenectomy, 29% after primary repair) and 21.1% after no bowel repair
Tsuneki et al[22], 2022	Case report, M, 75	Duodeno-jejunostomy	Lymphatic fistula that required lipiodol lymphangiography
Koo et al[23], 2022	Case report, M, 82	Duodeno-jejunostomy	Post-operative course uneventful
Khefacha et al[24], 2022	Case report, M, 67, SADF associated with necrotizing fasciitis of the thigh	Duodeno-jejunostomy	Died the next day due to multiple organ failure
Omran et al[25], 2021	Single-center retrospective, n = 24	Primary repair (n = 15); duodenal resection and GI reconstruction (technique not mentioned) (n = 6)	Duodenal leakage in 1 case
Tsuneki et al[26], 2020	Case report, M, 84	Duodeno-jejunostomy	No relapse 3 years after surgery
Makimoto et al[27], 2020	Case reports, 1 M, 64, and 2 M, 76	1 duodeno-jejunostomy and 2 primary repair	Post-operative course uneventful
Petrunić et al[28], 2020	Case report, M, 62	Primary repair	Laparotomy due to bleeding, 5th post-operative day
Malekpour et al[29], 2020	Case report, M, 75	Omental flap coverage, pyloric exclusion, and loop gastrojejunostomy	Post-operative course uneventful
Park et al[30], 2018	Case report, asymptomatic, M, 72	Primary repair	Post-operative course uneventful
Howard et al[31], 2015	Single-center retrospective, n = 14	Primary repair (n = 7), resection with primary anastomosis (n = 4), duodenal exclusion with gastrojejunostomy (n = 2)	Bile leak in 38% (n = 5), 43% primary repair vs 50% resection. The occurrence of bile leak after SADF repair was associated with increased mortality from 13% to 40%
Moulakakis et al[32], 2015	Case report, M, 74	Duodeno-jejunostomy	No relapse 20 months after surgery
Iwaki et al[33], 2015	Case report, M, 50	Duodeno-jejunostomy
Rodrigues dos Santos et al[34], 2014	Review, enteric repair in 331 cases of aortoduodenal fistula	Duodenorrhaphy (± omentum interposition) (n = 266), duodenal resection/reconstruction (n = 54), abdominal drainage (n = 4) cases, and no repair (n = 7)	Higher rates of fistula recurrence were reported with simple repair (41.8%); omental interposition was associated with lower mortality, independent of the repair technique
Farres et al[35], 2012	Case report, M, 76	Primary repair	Asymptomatic at 1-year follow-up
Tsujimoto et al[36], 2011	Case report, M, 73	Duodeno-jejunostomy	Uneventful recovery
Wijeyaratne et al[37], 2009	Case report, M, 65	Primary repair	Asymptomatic after 9 months
Antoniadis et al[38], 2009	Case report, M, 67	Primary repair	Asymptomatic after 4 months
Grassia et al[39], 2009	Case report, M, 72	Primary repair and omental patch	Post-operative course uneventful
Geraci et al[40], 2008	Case report, M, 59	Gastrojejunal Roux anastomosis	Asymptomatic after 6 months
Mohammadzade et al[41], 2007	Case report, M, 70	Primary repair	Post-operative course uneventful
Biancari et al[42], 2006	Case report, M, 58	Primary repair	Asymptomatic after 8 months

M: Male; F: Female; SADF: Secondary aortoduodenal fistula; pts: Patients.

Management of SADF. After initial resuscitation, definitive management of SADF requires simultaneous hemorrhage control, eradication of infected material, and durable arterial and enteric reconstruction. Observational data consistently link failure to remove infected prosthetic material with recurrent sepsis or re-fistulation. Thus, when feasible, complete aortic graft explantation and debridement remain the most reliable means of infection control[43]. While emergent EVAR provides rapid hemostasis and superior early survival in unstable patients, observational data and guideline recommendations emphasize that EVAR alone frequently fails to eradicate infection and is associated with higher rates of recurrent sepsis and reintervention. Therefore, EVAR is often best used as a bridge to staged open explantation when feasible[44,45]. Some centers employ emergent EVAR to control bleeding, followed by delayed graft excision and duodenal repair once the patient recovers. In patients who can tolerate open surgery, the most effective approach to controlling infection involves complete removal of the graft, extensive tissue debridement, and in-situ reconstruction using cryopreserved allografts or autologous venous conduits. When biologic conduits are not available or if the abdomen is hostile, alternatives such as antibiotic-impregnated or silver-coated prostheses and extra-anatomic bypass procedures can be considered. Postoperative antibiotic therapy should be individualized but generally extends for at least six weeks and may even be lifelong if complete source control is not achieved. Open approaches carry higher immediate operative stress and perioperative mortality but improved long-term infection control vs retained endografts[21,46].

Options include: (1) Open explantation + in-situ reconstruction with biologic or antibiotic-impregnated graft (bovine pericardial, cryopreserved allograft, silver-coated Dacron) + definitive bowel resection/repair - widely reported as the standard when the patient can tolerate open surgery. Several modern series favor in-situ biologic grafts for infection control and durability[10,12]; (2) Extra-anatomic bypass (axillo-bifemoral) + explantation - used historically in some infected cases, but associated with limb ischemic complications and lower long-term patency; and (3) EVAR/stent grafting - commonly used as a bridge in unstable patients to control hemorrhage; however, EVAR alone when infection exists may lead to persistent infection, recurrent bleeding, and later mortality. Several reports support EVAR as a temporizing, not definitive, treatment in infected SAEF[17].

ADF series report that in-situ reconstruction, which involves complete excision of the infected aortic segment and replacement with a conduit placed within the native anatomic course - using cryopreserved allografts, pericardial/biologic conduits, or antibiotic-treated prostheses - achieves effective infection control when combined with aggressive debridement and enteric repair, with acceptable mid-term patency and lower rates of stump-related complications[47,48]. In contrast, extra-anatomic axillobifemoral bypass with aortic exclusion historically provided an alternative in contaminated fields or unstable patients. However, cohorts document higher late graft occlusion, limb ischemia, and the unique risk of aortic stump blow-out[49-51]. Despite these differences, the ADF series shows no consistent survival advantage of in-situ reconstruction over extra-anatomic bypass once patient physiology and operative urgency are taken into consideration[10,21,52]. As a result, in-situ reconstruction is generally favored when the patient can tolerate aortic cross-clamping and biologic conduits are available, whereas extra-anatomic axillobifemoral bypass remains a justified option for physiologically fragile patients or when gross contamination or limited graft availability precludes an in-situ repair.

Explanation of an infected endograft in the setting of EVAR-related ADF - particularly devices with suprarenal fixation - poses unique and formidable technical challenges. Complete removal commonly requires extended suprarenal or supraceliac aortic cross-clamping to gain proximal control, and transection or dissection of the aortic neck can be complicated by incorporation of bare springs into the aortic wall, dense inflammatory adhesions, or erosion into adjacent duodenum or retroperitoneum; these features increase the likelihood of intraoperative aortic injury, prolonged operative time and blood loss, and the need for supravisceral control. Removal of suprarenal fixation may also avulse or otherwise jeopardize the renal or visceral artery ostia, necessitating adjunctive renal/visceral revascularization techniques (direct patch/repair of the artery, reimplantation, bypass grafting, or complex hybrid maneuvers), or in some cases nephrectomy when renal ischemia or arterial injury is unrecoverable[53,54].

Reported perioperative mortality for explantation for infection or ADF is high in many cohorts (single-center studies variably report overall perioperative mortality in the range of approximately 20%-25% for urgent/infected cases), and renal dysfunction, prolonged intensive care stays, and multi-organ complications are common after supravisceral clamping and complex visceral/renal reconstructions[25,53,55-59]. Early multidisciplinary planning, use of adjuncts to reduce ischemic time (sequential clamp strategies, temporary shunts, kidney cooling where feasible), and careful patient selection for complete explantation vs staged or partial strategies are needed, recognizing that incomplete source control risks ongoing infection while aggressive explantation carries substantial physiologic cost[55-59]. Duodenal repair techniques - duodenal repair should be individualized: Small, well-vascularized defects may be closed primarily in two layers; larger or devitalized segments warrant resection and reconstruction (primary anastomosis or duodenal diversion/bypass). Omental or muscle flap interposition to separate the vascular reconstruction from the enteric suture line is widely recommended and associated with reduced fistula recurrence in observational series and by guideline consensus[34,43,60,61].

Duodenal repair in the setting of ADF has three primary objectives: (1) To ensure a durable, well-vascularized closure of the enteric defect to prevent leakage and sepsis; (2) To minimize ongoing contamination of the aortic reconstruction or vascular conduit; and (3) To select an approach compatible with the patient’s physiologic reserve and the degree of local tissue damage. The available evidence consists primarily of observational studies, such as case series and systematic reviews of reported cases and trauma cohorts. There are no randomized trials comparing all duodenal techniques in ADF. Therefore, recommendations must be tailored to the individual patient, considering factors like defect size, tissue viability, contamination, and overall patient stability[34].

Based on current evidence and clinical experience, we propose a practical algorithm for the management of duodenal defects during ADF repair. The approach is guided by defect size, tissue viability, and the degree of contamination. When feasible, a tension-free, two-layer primary duodenorrhaphy reinforced with omental interposition is recommended. Larger or tenuous defects should be managed with a Roux-en-Y duodenojejunostomy to provide a secure and well-vascularized reconstruction. Pyloric exclusion is reserved for rare, complex injuries. Wide debridement, placement of drains, and interposition of well-vascularised tissue between the duodenum and the aortic graft are implemented to minimize leaks and recurrent fistulization.

When the duodenal defect is small and the adjacent tissue is healthy, a two-layer primary duodenorrhaphy with routine interposition of well-vascularised tissue (most commonly the greater omentum) can be the preferred first-line approach. Omental interposition between the enteric repair and the aortic graft is consistently recommended across vascular and surgical reviews. This practice is associated with lower rates of early graft contamination and better short-term outcomes in observational studies[34,62,63]. Several vascular surgery series report improved early outcomes and lower graft contamination when immediate omental coverage is used, which is associated with better 30-day survival in some cases[60].

Primary repair alone is generally acceptable for defects occupying less than approximately half the circumference and where tissue is not grossly inflamed or ischemic. Reported leak/fistula rates in selected series are low but variable (trauma series report leak rates 6%-11%)[64,65]. When primary repair is tenuous due to inflamed, devitalized, or fragile margins, reinforcement with vascularised tissue is indicated. Two commonly used reinforcement strategies are a jejunal serosal patch and an omental pedicle flap placed over the repair. Jejunal serosal patching is technically straightforward, provides vascular support to the repair, and avoids bowel resection[66]. Although it has been reported to reduce failure rates in selected cohorts, the evidence remains limited to case series. Omental interposition between the aortic repair and the duodenal repair or graft has the dual advantage of vascularity and immunologic activity and is consistently recommended in vascular literature, as it reduces contamination of the vascular conduit and may lower early mortality[34,62,63].

For large defects, defects involving the third/fourth portions of the duodenum, or when prior primary repair has failed, resection of the fistulous portion of duodenum or bowel and diversionary or reconstructive procedures should be strongly considered. Duodenojejunostomy includes the creation of an end or side duodenojejunostomy to bypass the damaged segment (often the 3^rd/4^th portion), which may be stapled off and remain in situ if resection is technically challenging (Figure 1). Feeding jejunostomy and drainage are commonly added. Duodenojejunostomy is indicated for significant segmental defects in the third or fourth portions of the duodenum that cannot be primarily closed with a two-layer technique, particularly when resection of the injured duodenum is necessary, but the pylorus can be preserved. The advantages are that there is a single anastomosis to manage and monitor, and that reconstruction is shorter than in combined diversion procedures. A Roux-en-Y duodenojejunostomy, which involves excising the defect and reconstructing to an isolated Roux limb, provides a physiological diversion. This approach allows for a low-pressure reconstruction with minimal fistula rates when performed by experienced surgical teams. It is increasingly preferred for large or complex iatrogenic injuries where primary repair is unlikely to heal. Although bowel mobilization is required and the procedure is technically demanding, recent case series indicate good outcomes, and it may be favored when primary repair is expected to fail, with acceptable leak rates reported in contemporary studies (small series reported 75% uncomplicated recoveries), although cohorts are small and follow-up is limited[67,68]. However, high-quality comparative data are still lacking[68].

Tube duodenostomy through the defect is a historical option for large or complex D2 injuries that has largely fallen out of routine use because of high morbidity in older reports. It might still be considered a salvage option in very selective cases[64,69]. Pyloric exclusion (pyloroplasty/pyloric closure combined with gastrojejunostomy) was historically widely used for severe duodenal trauma to divert gastric contents away from the duodenum and protect repairs. However, multicentre trauma and registry analyses have since questioned the routine use of pyloric exclusion. Several comparative series have found no mortality benefit, and in some groups, it has been associated with increased complications and longer hospital stays compared to simpler repair strategies. Therefore, pyloric exclusion should be reserved for selected injuries, such as massive duodenal disruption, combined pancreaticoduodenal injuries, or when the surgeon determines that diversion is necessary[66,70-73].

Historically, pyloric exclusion + gastrojejunostomy (including Roux variants) was widely recommended for severe duodenal injuries (series from 1970 to 1980). Modern trauma series and registry analyses have questioned routine use. Studies show no clear mortality benefit, and some show longer hospital stay and possibly higher complication rates when pyloric exclusion is used. However, in selected complex injuries (massive tissue loss, combined pancreatic lesions, delayed repair) diversion with pyloric exclusion + GJ remains a commonly recommended option. When a GJ is required, Roux-en-Y (Figure 1) is often favored to reduce bile reflux and long-term gastric symptoms, but there are no randomized trials in the specific trauma/ADF population directly comparing Roux-en-Y vs Billroth II in this setting[70,71].

Roux-en-Y (Figure 1) is preferred if long-term prevention of bile/gastric reflux is a priority and the patient is stable enough and can tolerate a longer operative time. It is favored by many for durable diversion[74-76]. Billroth II is selected when it is essential to minimize operative time, particularly in damage-control situations or hostile abdominal conditions, even if it comes with a theoretical higher risk of bile reflux. Evidence from literature on gastric and pancreaticoduodenal surgeries indicates that while short-term morbidity may be similar, the functional outcomes differ between the two techniques[77,78] (Figure 1).

Operative adjuncts and general principles that improve outcomes include wide debridement of necrotic tissue, meticulous drain placement, and interposition of vascularized tissue (omental flap/jejunal patch) between enteric repair and any aortic repair or prosthesis[34,76]. Routine placement of drains, feeding gastrostomy or jejunostomy for early enteral nutrition, aggressive sepsis control, and multidisciplinary care influence outcomes more than the small differences between RY and BII in many settings[64].

Untreated ADF carries a nearly 100% mortality rate. Open repair results in a 25%-40% in-hospital mortality rate[61]. Older pooled analyses indicated high mortality, while more recent single-center studies show improved outcomes with multidisciplinary approaches and earlier detection. Contemporary reports suggest perioperative mortality ranges from 20% to 40%, with emergency cases facing higher mortality rates. Chopra et al[79] reported a 60-day mortality of 46%, with gastrointestinal complications and advanced age as key predictors. Bartley et al[10] found 30-day and 90-day mortalities of 35% and 39%, respectively, but noted a significant improvement over time due to better perioperative care and optimal surgical strategies. These findings suggest that contemporary management may reduce, but not eliminate, the high risk of death. Long-term outcomes are influenced by infection control and graft selection (as seen in representative data from Kakkos et al’s pooled analysis[46], Bartley’s 20-year experience[10], and Sieber et al[17]). Staged EVAR combined with open repair has demonstrated improved outcomes in some studies. A systematic review reported a comparatively low 30-day mortality of 8.5% for endovascular management of aortoenteric fistulas, although high rates of rebleeding and infection were observed within 1-2 years[80]. In contrast, a recent multi-centre study by Narayanan et al[81] found that bridging EVAR for SADF did not significantly reduce mortality compared with open repair. Poor outcome predictors include advanced age, hemodynamic instability, renal failure, and ongoing infections. In cases of graft infection, various organisms may be identified, including Gram-positive cocci, Gram-negative bacilli, and polymicrobial infections. Targeted, prolonged antibiotic therapy is essential, guided by culture results. Extended or lifelong antibiotic therapy is often necessary, especially when infected tissue cannot be entirely excised.

Definitive surgery that includes source control (graft explant and intestinal resection/repair) along with appropriate vascular reconstruction offers the best chance for a cure. The selection of biological and in-situ grafts - such as bovine pericardium and cryopreserved homografts - is increasingly common in modern practices to reduce the risk of reinfection. Due to the lack of randomized data, most evidence remains observational or based on case studies.

In our case, we present a 79-year-old male with a history of open repair of a ruptured abdominal aortic aneurysm, who subsequently developed an ADF. Definitive management was achieved with in-situ aortic reconstruction using a bovine pericardial graft, combined with duodenojejunostomy for gastrointestinal reconstruction. This approach provided both durable vascular repair and safe diversion of the intestinal tract. The patient’s uneventful postoperative course supports the role of biologic aortic grafts, fistula resection, and gastrointestinal reconstruction as effective options in the complex setting of ADF.

It is important to acknowledge the limitations of the existing evidence. Current literature mostly consists of retrospective case series and cohort studies, with a lack of randomized controlled trials that specifically compare these techniques in ADF cases. The reported rates of leaks and fistulas, as well as other outcomes, come from heterogeneous observational series (including trauma, iatrogenic injuries, and graft-related ADF), small case series focused on Roux reconstructions, and pooled literature reviews spanning multiple decades. Reported duodenal leak rates vary significantly, ranging from 0% to over 30%, depending on factors such as injury severity, timing of surgery, and the selection of patient cohorts. This variability underscores the necessity for individualized surgical judgment and selective use of more complex reconstructions[21,64,67]. A multidisciplinary approach that includes vascular surgeons, general surgeons, gastroenterologists, interventional radiologists, anesthesiologists, and infectious disease specialists offers the best chance of survival. Key areas for research include developing graft materials resistant to infection and erosion, enhancing imaging techniques for early detection, and standardizing treatment protocols to optimize patient outcomes.

In addition, an interesting element of this salvage surgical treatment is who will perform the complex gastrointestinal reconstruction? Can we expect the trauma team or the acute care surgery team to do so? In the last ten to twenty years, vascular surgery teams have worked closely with Hepatico-Pancreatic-Biliary teams to collectively resect pancreatic tumors invading surrounding vasculature and simultaneously reconstruct the underlying vascular anatomy. As such, perhaps it is worth considering calling upon members of the Hepatico-Pancreatic-Biliary team in tertiary-level hospitals to perform these complex gastrointestinal reconstructions while addressing ADFs as a team.

CONCLUSION

ADF, although rare, is a life-threatening condition that requires prompt recognition and intervention. Management of the duodenal component in ADF is a critical determinant of overall outcome. Current evidence, although limited to case series and retrospective reviews, consistently supports a tailored approach based on defect size, tissue viability, contamination, and patient stability. Due to the absence of prospective comparative data, multicenter clinical trials are needed to better define optimal repair techniques and long-term outcomes.