Recurrent Aortic Infections Due to Unrecognized Aorto-Enteric Fistula

We report a case of an infrarenal abdominal aortic aneurysm (AAA) with unrecognized primary aortoduodenal fistula (ADF), treated by endovascular aortic repair (EVAR). Endograft infection was diagnosed 12 months thereafter. The associated ADF was uncovered during open surgery, which included endograft extraction, in situ aortic reconstruction with a cryopreserved homograft (CHG) and duodenal repair. The patient was urgently reoperated in the early postoperative course, due to CHG rupture and subsequent hemorrhagic shock. After establishing control of hemorrhage, CHG was explanted, followed by aortic ligation and extraanatomical reconstruction with axillofemoral bypass. The importance of timely diagnosis of primary ADF prior to AAA repair, as well as treatment options and optimal materials for simultaneous aortic and bowel reconstruction in the setting of primary or secondary ADF, are discussed.