Spontaneous aortoduodenal fistula: successful treatment by extra-anatomic vascular bypass

A 77-year-old woman was admitted to hospital with massive upper gastrointestinal bleeding of obscure etiology and a palpable abdominal aortic aneurysm. A spontaneous aortoduodenal fistula, discovered at operation, was treated successfully by resection of the aneurysm, aortic closure, lateral duodenal repair and axillobilateral femoral grafting. The three clues to the correct diagnosis were: a palpable, pulsatile abdominal mass, recurrent abrupt cardiovascular collapse and significant upper gastrointestinal bleeding with no obvious source. The conventional method of treatment--aortic resection, duodenal repair, and intra-abdominal aortic grafting--is followed by secondary infection and aortic anastomotic bleeding, and by death in nearly 50% of the patients. The method of treatment used by the authors in this patient may be safer and deserves further consideration.