Successful management of a secondary aorto-duodenal fistula with an infected prosthesis and hemorrhagic shock.

INTRODUCTION

Secondary aortoenteric fistula is a rare but life-threatening complication of aortic reconstructive surgery. It typically presents with gastrointestinal bleeding and sepsis and requires early recognition and prompt surgical intervention to prevent fatal outcomes.

CASE PRESENTATION: We report the case of a 62-year-old man with a history of an aortobifemoral bypass performed 2 years earlier for aortoiliac occlusive disease. He presented with massive hematemesis, high-grade fever, and severe epigastric pain. On admission, he was in hemorrhagic shock. Laboratory studies showed profound anemia and an inflammatory syndrome. CT angiography revealed peri-graft air and right iliac thrombosis, raising suspicion of graft infection or a secondary aortoenteric fistula. Endoscopy confirmed graft exposure through a duodenal ulcer. Broad-spectrum antibiotics were initiated. Recurrent bleeding and hemodynamic collapse prompted emergency laparotomy. Complete explantation of the infected graft and primary duodenal repair were performed. Revascularization was achieved by a left aorto-iliac bypass using the autologous right femoral vein. Cultures grew Escherichia coli. Postoperative recovery was favorable after targeted antibiotic therapy and intensive care monitoring.

DISCUSSION: This case highlights the diagnostic challenges and therapeutic complexity of a secondary aortoduodenal fistula. CT angiography combined with endoscopy allows rapid diagnosis, while timely surgery and biological reconstruction are essential for survival.

CONCLUSION

A secondary aortoduodenal fistula should be suspected in any patient with a prior aortic graft presenting with upper gastrointestinal bleeding. Early multidisciplinary management and autologous reconstruction offer the best chance of a successful outcome.