Management of Leaking Abdominal Aortic Aneurysm
Leaking abdominal aortic aneurysm requires immediate surgical intervention, with endovascular repair (EVAR) being the preferred treatment option in hemodynamically stable patients with suitable anatomy to reduce morbidity and mortality.
Initial Assessment and Diagnosis
Clinical Presentation
- Acute onset of abdominal and/or back pain
- Hemodynamic instability (in free rupture) or stability (in contained rupture)
- Pulsatile abdominal mass
- Hypotension may be present (but permissive hypotension is recommended)
Immediate Diagnostic Workup
- In hemodynamically stable patients: CT imaging with contrast is recommended to evaluate whether the AAA is amenable to endovascular repair 1
- CT protocol should include:
- Non-contrast phase to detect intramural hematoma
- Contrast phase to identify active leaks
- Imaging of iliac and femoral arteries for planning intervention 1
- Ultrasound may be used for rapid bedside assessment if CT is not immediately available
Treatment Algorithm
1. Hemodynamically Stable Patients with Contained Rupture
First-line treatment: Endovascular repair (EVAR) if anatomy is suitable 1
Anesthesia considerations: Local anesthesia is preferred over general anesthesia during EVAR to reduce perioperative mortality 1
Access approach: Ultrasound-guided percutaneous access and closure is recommended over open cutdown when common femoral artery anatomy is suitable 1
2. Hemodynamically Unstable Patients or Unsuitable Anatomy for EVAR
- Emergency open surgical repair is indicated
- Immediate transfer to operating room for hemorrhage control
- Consider endovascular balloon occlusion under fluoroscopy to reduce excessive bleeding 1
3. Intraoperative Management
- Permissive hypotension is beneficial to decrease bleeding rate until aortic control is achieved 1
- Target systolic blood pressure: maintain adequate end-organ perfusion while minimizing bleeding
- Aggressive resuscitation once aortic control is achieved
Post-Procedure Management and Follow-up
After EVAR
- Initial imaging at 1 month post-procedure using CT angiography and duplex ultrasound 1
- Follow-up imaging at 6-12 months, then yearly for at least 5 years 2
- Monitor for endoleaks (most common complication):
After Open Repair
- Early CT within 1 month, then yearly for first 2 years
- Every 5 years thereafter if findings remain stable 1
Special Considerations and Pitfalls
Common Pitfalls
- Delayed diagnosis: Mortality increases dramatically with time (54% at 6 hours, 76% at 24 hours) 1
- Misdiagnosis: Contained rupture may be mistaken for other causes of back pain
- Inadequate resuscitation: Balance between permissive hypotension and end-organ perfusion is critical
- Failure to recognize endoleaks: Regular surveillance is essential after EVAR
Risk Factors for Poor Outcomes
- Proximity of rupture to aortic valve (higher risk with more proximal location) 1
- Chronic anticoagulation (increases risk of reintervention, late conversion, and mortality) 1, 2
- Advanced age and multiple comorbidities (though these factors generally favor EVAR over open repair) 2
Special Anatomical Considerations
- Vertebral body erosion may be present in chronic contained ruptures 1
- Juxta- or para-renal AAA involvement requires specialized approaches (fenestrated EVAR or open repair) 2
- Connective tissue disorders (e.g., Marfan syndrome) generally contraindicate EVAR 2
The management of leaking abdominal aortic aneurysm requires rapid diagnosis, prompt intervention, and a team-based approach. While endovascular repair has emerged as the preferred treatment option for suitable candidates, open surgical repair remains necessary for patients with unsuitable anatomy or hemodynamic instability.