Primary aortoduodenal fistula: a case report and review of the literature.

The case of a 22-year-old female with spontanteous aortoduodenal fistula is presented, and a group of 185 other cases from the world literature are analyzed. Three additional cases were identified which did not appear to have an underlying pathologic process involving the aorta. Successful surgical correction depends upon a high index of suspicion. In the majority of patients the "herald bleed" allows a period for aggressive investigation. The "herald bleed" is usually rapid, painless, of large volume, and may present as hematochezia. Normal barium studies and endoscopy should heighten suspicion in patients with gastrointestinal hemorrhage. Arteriography may define the case of bleeding and may also delineate the nature and extent of the vascular disease. If the aortic wall is of sufficient quality, direct oversewing has the advantage of avoiding the use of a foreign body in a potentially infected field. In the vast majority of patients a vascular prosthesis is required. Consideration should be given to subcutaneous extraanatomic reconstruction.