Management of Secondary Aortoduodenal Fistula: The Role of Emergency Endovascular Repair and Timing of Definitive Open Surgery in a Single-Center Case Series.

BACKGROUND

Secondary aortoduodenal fistula (SADF) is a rare but life-threatening complication after abdominal aortic surgery, characterized by catastrophic hemorrhage and persistent infection. Emergency endovascular aortic repair (EVAR) is increasingly performed initially as a less invasive approach for rapid hemostasis in patients presenting with hemorrhagic shock; however, it does not eliminate the underlying source of infection. Although definitive open surgery to remove the infectious source remains essential, the optimal timing has not been established due to the rarity of this condition. Therefore, we evaluated emergency EVAR as an initial hemostatic strategy and the association between timing of definitive surgery and clinical outcomes.

METHODS

We retrospectively reviewed six consecutive patients with SADF treated at our institution from 2016 to 2025. Emergency EVAR was performed in patients presenting with hemorrhagic shock, followed by definitive surgery. Until 2021, definitive surgery was performed electively after stabilization of the patient's general condition, whereas since 2022, it has been performed as early as clinically feasible.

RESULTS

Emergency EVAR was performed in five patients to achieve hemostasis, and none of the patients died before definitive surgery. During follow-up, four patients died of sepsis due to recurrent infection within 2 years after surgery. Longer intervals from diagnosis to definitive surgery were observed in these patients.

CONCLUSION

Emergency EVAR was an effective life-saving strategy for initial hemostasis. However, unfavorable outcomes were associated with prolonged delays before definitive surgery, suggesting that earlier transition to definitive surgery for infection control may be related to overall outcomes.