What is the treatment (Tx) for a ruptured abdominal aortic aneurysm (AAA)?

Treatment of Ruptured Abdominal Aortic Aneurysm

For patients with ruptured abdominal aortic aneurysm (rAAA) who have suitable anatomy, endovascular aneurysm repair (EVAR) is recommended over open surgical repair to reduce the risk of morbidity and mortality. 1

Initial Management

1. Rapid Assessment and Stabilization

   • Implement permissive hypotension (target systolic BP 70-90 mmHg) to decrease bleeding rate 1
   • Avoid aggressive fluid resuscitation which can increase bleeding by disrupting clot formation
   • Establish large-bore IV access and prepare for massive transfusion

2. Immediate Diagnostic Imaging

   • For hemodynamically stable patients, obtain CT imaging to evaluate AAA anatomy for potential endovascular repair 1
   • CT should include arterial phase imaging of entire aorta, iliac and femoral arteries to plan intervention 1
   • Unstable patients may need to proceed directly to the operating room

Definitive Treatment

Endovascular Aneurysm Repair (EVAR)

• First-line treatment for anatomically suitable candidates 1
• Benefits compared to open repair:
  • Reduced 30-day mortality (15-19% vs 25-49%) 2
  • Decreased perioperative morbidity 1
  • Shorter hospital stays (10 days vs 21 days) 2
  • Lower rates of ventilator-dependent respiratory failure (5% vs 42%) 2

Open Surgical Repair

• Indicated when:
  • Patient anatomy is unsuitable for EVAR
  • Endovascular expertise or equipment is unavailable
  • Patient is too unstable for CT imaging or transfer to endovascular suite

Anesthesia Considerations

• Local anesthesia is preferred for endovascular repair to reduce perioperative mortality 1
• General anesthesia required for open repair and may be necessary for complex EVAR cases

Procedural Details

EVAR Procedure

• Ultrasound-guided percutaneous femoral access is recommended over surgical cutdown when feasible 1
• Typically involves deployment of a bifurcated or aorto-uni-iliac stent graft
• May require adjunctive procedures (coil embolization, additional stent placement)
• Intraoperative angiography to confirm successful aneurysm exclusion

Open Repair Procedure

• Midline laparotomy with proximal and distal control of the aorta
• Replacement of the aneurysmal segment with a synthetic graft
• Higher blood loss and longer operative time compared to EVAR

Post-Procedure Management

• Intensive care monitoring for all patients
• Vigilance for abdominal compartment syndrome, particularly after EVAR
• Monitor for endoleaks in EVAR patients
• Early mobilization and respiratory support as needed
• Surveillance imaging at 1 month, 6-12 months, and annually thereafter for EVAR patients 3

Complications to Monitor

• EVAR-specific complications:

  • Endoleaks (particularly Type I and III requiring immediate correction) 3
  • Access site complications
  • Limb occlusion
  • Device migration

• Open repair complications:

  • Myocardial infarction
  • Respiratory failure
  • Renal failure
  • Ischemic colitis
  • Spinal cord ischemia
  • Incisional complications

Pitfalls and Caveats

• Not all patients have anatomy suitable for EVAR - careful evaluation is essential
• Institutional protocols for rAAA management improve outcomes regardless of repair method 1
• Team-based approach with immediate availability of vascular surgeons, anesthesiologists, and OR staff is critical
• Delays in treatment dramatically increase mortality (54% at 6 hours, 76% at 24 hours after rupture) 1
• Long-term surveillance is mandatory after EVAR to detect late complications

The evidence strongly supports EVAR as the preferred approach for anatomically suitable patients with rAAA, with multiple studies showing reduced perioperative mortality and morbidity compared to open repair 1, 2.