Aortoduodenal syndrome: evolving management of a rare cause of duodenal obstruction in the endovascular era

Objective Aortoduodenal syndrome (ADS) is a very rare complication of abdominal aortic aneurysm (AAA), characterized by extrinsic compression of the duodenum leading to proximal bowel obstruction. This systematic review sought to aggregate all published ADS cases, with emphasis on patient demographics, diagnostic workup, treatment modalities, and outcomes.Methods A systematic literature search was conducted across MedLine/PubMed, Scopus, Embase, and Web of Science from database inception through 2 February 2026, following PRISMA guidelines. Reports containing original patient data describing duodenal obstruction attributable to abdominal aortic aneurysm (AAA), irrespective of rupture status, were eligible for inclusion, provided that the obstruction was attributed to aneurysmal mass effect. Extracted variables included demographic characteristics, clinical presentation, aneurysm morphology, diagnostic imaging, therapeutic interventions, and follow-up results. This study has been registered in PROSPERO (CRD420251456530).Results Forty studies encompassing 44 patients were analyzed. The cohort was predominantly male (86.6%), with a mean age of 74.5 years. The most common presenting symptoms were vomiting, abdominal pain, and a palpable pulsatile abdominal mass. Computed tomography served as the primary diagnostic tool, whereas upper gastrointestinal contrast series and endoscopy were employed mainly to exclude alternative obstructive etiologies. The third duodenal portion was the most frequently compressed segment, with a median aneurysm diameter of 72.5 mm. Surgical intervention was performed in most patients, comprising open aortic repair (n = 18) or endovascular aneurysm repair (EVAR, n = 13). Gastrointestinal bypass procedures were reserved for selected or salvage situations. Outcome data were available for 42 patients. Mortality was reported in 6 patients (14.3%), including two patients who did not undergo operative treatment. Among the 39 patients who underwent operative treatment, postoperative complications were reported in 9 patients (23.1%).Conclusion EVAR represents an increasingly reported treatment option in anatomically suitable patients, particularly those at high operative risk; however, the available evidence remains insufficient to establish EVAR as the preferred first-line treatment. Treatment should be individualized according to aneurysm anatomy, clinical condition, operative risk, and severity of duodenal obstruction.