Primary Aortoduodenal Fistula: A Case Report and Recent Literature Review (2021-2025)

Primary aortoduodenal fistula (PADF) is a rare but life-threatening cause of gastrointestinal bleeding, most commonly resulting from an abdominal aortic aneurysm eroding into the duodenum.Diagnosis is particularly challenging because of its nonspecific clinical presentation and the limited sensitivity and technical challenges of endoscopy.We present the case of an 89-year-old man with significant cardiovascular comorbidities, who developed acute abdominal pain and transient malaise, followed by massive upper gastrointestinal bleeding leading to hemorrhagic shock.Initial management included aggressive resuscitation with crystalloids, vasopressors, and initiation of a massive hemorrhage protocol.Due to severe hemodynamic instability, we could not perform a computed tomography angiography (CTA), and the patient underwent emergent laparotomy.Intraoperative upper endoscopy via surgical gastrostomy revealed a fistula between the infrarenal aorta and the fourth portion of the duodenum.Surgical intervention included end-to-end aorto-aortic bypass with a prosthetic graft, and primary duodenal repair with omental interposition.The postoperative course was complicated by ischemic colitis, respiratory failure, and progressive multi-organ failure.Despite maximal supportive measures, the patient's condition deteriorated, and care was ultimately transitioned to comfortfocused management.In our review, one key finding is the increasing trend toward endovascular and hybrid approaches for managing PADF.These strategies may facilitate more rapid hemodynamic stabilization in critically ill patients.More recently, exclusively endovascular or endoscopic procedures have been reported as potential destination therapies in carefully selected cases, particularly when conventional open repair is not feasible.PADF remains a surgical emergency with a high risk of mortality.This case highlights the importance of early recognition, aggressive resuscitation, and prompt surgical intervention.Multidisciplinary collaboration and individualized decision-making, including consideration of hybrid endovascular and open techniques, are essential to optimize outcomes in this rare but catastrophic condition.