Aorto-duodenal fistula (ADF) is a rare clinical condition characterized by abnormal communication between the 3rd or 4th portion of the duodenum and the aorta, typically associated with aneurysmal disease. The incidence of ADF is expected to increase, however, there remains a lack of consensus on the optimal approach for intestinal restoration. In this study, we present three cases of ADF and their respective treatments using three distinct surgical techniques. Initially, endovascular aortic repair was employed as a life-saving procedure, followed by elective open repair. The choice of surgical technique was determined based on the patients' overall health conditions and the specific characteristics of the duodenal defect. In all cases, an omental patch was utilized to separate the aortic plane from the intestinal staple lines, providing additional protection for the sutures. The importance of a multimodal treatment strategy cannot be overstated, given the complex interplay of vascular, intestinal, and septic factors involved in the treatment of ADF.