Recurrent aortoduodenal fistula: a lesson in management

Aortoenteric fistula (AEF) is a rare but often lethal complication of aortic reconstructive surgery. The diagnosis is often delayed due to the high percentage of false-negative using upper gastrointestinal series, angiography, and endoscopy. The diagnosis of AEF must be considered in any patient with a prosthetic graft and gastrointestinal bleeding. There are essentially two modalities of treatment: replacement of the graft or total removal of all prosthetic material and the construction of an extra anatomic bypass. A case report of a recurrent aortoduodenal fistula is presented that illustrated both delay in diagnosis and inappropriate treatment. We agree with the general trend in the literature that the appropriate management of this devastating complication is complete removal of the prosthetic graft, wide drainage, high-dose antibiotics, and extra anatomic bypass. Any deviation from these basic treatment steps - such as replacement of the graft - ignores the infectious component of this complication and can result in the devastating lethal complication seen in this patient. With appropriate suggested management this once uniformly fatal complication can be treated effectively, resulting in an acceptable morbidity and mortality.