Nuances in Secondary Aortoduodenal Fistula Management: Presentation of Two Cases and Review of the Literature.

IntroductionSecondary aortoduodenal fistula (SADF) is a rare but life-threatening complication of abdominal aortic aneurysm (AAA) repair, most commonly involving the third or fourth part of the duodenum. Diagnosis is challenging, and management remains controversial.Case PresentationWe report two cases of SADF following open AAA repair. Both patients presented with herald bleed preceding massive gastrointestinal haemorrhage and haemodynamic collapse. Initial stabilisation was achieved with emergency endovascular stent grafting (EVAR). In the first case, the patient underwent definitive two-stage repair with axillobifemoral bypass, graft explantation and duodenectomy with duodenojejunal anastomosis, and remains well at three-year follow-up. The second patient underwent duodenectomy with duodenojejunal anastomosis, but due to severe comorbidities and occluded femoral arteries the aortic graft was left in situ. Despite initial recovery, he developed overwhelming sepsis and died on postoperative day 10.DiscussionThese cases highlight the diagnostic and therapeutic challenges, as well as the complex decision-making required in these patients. Endovascular repair provides life-saving haemostasis and can serve as a bridge to surgery. Definitive management must address both the aortic and duodenal components, tailored to patient comorbidities and anatomy.ConclusionSADF requires prompt recognition and multidisciplinary management. EVAR is invaluable in acute stabilisation, but surgical definitive repair offers the best long-term outcomes.