What is the management of a ruptured and leaking abdominal aortic aneurysm (AAA)?

Management of Ruptured and Leaking Abdominal Aortic Aneurysm

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

Initial Assessment and Stabilization

• Hemodynamic Assessment:

  • Determine if patient is hemodynamically stable or unstable
  • Implement permissive hypotension in bleeding patients to decrease bleeding rate 1
  • Target systolic blood pressure: maintain enough for organ perfusion while minimizing bleeding

• Immediate Interventions:

  • Establish large-bore IV access
  • Type and cross for blood products
  • Activate massive transfusion protocol if needed
  • Transfer to operating room for immediate hemorrhage control in unstable patients

Diagnostic Imaging

• For hemodynamically stable patients:

  • CT imaging is recommended to evaluate whether the AAA is amenable to endovascular repair 1
  • CT should cover entire aorta plus iliac and femoral arteries to provide sufficient information for planning treatment 1
  • Non-contrast phase followed by contrast phase to detect intramural hematoma and contrast leaks 1

• For hemodynamically unstable patients:

  • Consider immediate transfer to operating room without imaging
  • Bedside ultrasound may help confirm diagnosis if available without delaying definitive care

Treatment Options

Endovascular Aortic Repair (EVAR)

• First-line treatment if anatomically suitable 1, 2
• Benefits:
  • Lower 30-day mortality (21% vs 34% for open repair) 1
  • Superior long-term survival (between 90 days and 3 years) 1
  • Reduced perioperative morbidity 2
• Procedural considerations:
  • Local anesthesia is preferred over general anesthesia to reduce perioperative mortality 1
  • Consider endovascular balloon occlusion under fluoroscopy to reduce excessive bleeding 1

Open Surgical Repair

• Indicated when:
  • Endovascular repair is not anatomically feasible
  • Immediate access to endovascular equipment/expertise is not available
  • Patient has hemodynamic instability requiring immediate intervention
• Associated with higher perioperative mortality (approximately 34-45%) 3

Special Considerations

Contained Rupture

• Contained ruptures (where bleeding is sealed by periaortic structures) may present with:

  • Acute onset of back and/or chest pain 1
  • Hemodynamic stability despite rupture 1
  • Possible vertebral body erosion in chronic cases 1

• Even with contained rupture, urgent treatment is required due to risk of free rupture 1

Complications to Monitor

• Abdominal Compartment Syndrome:

  • Associated with poor survival 3
  • Monitor intra-abdominal pressure
  • Consider decompressive laparotomy if diagnosed

• Intestinal Ischemia/Infarction:

  • Associated with poor survival 3
  • Monitor for signs of bowel ischemia

Team-Based Approach

• Implement "rupture protocols" that include:
  • Early imaging when possible
  • Permissive hypotension
  • Rapid transfer to operating room
  • Coordination between vascular surgery, anesthesia, and critical care

Post-Procedure Management

• Intensive care monitoring
• Optimal medical therapy including:
  • Blood pressure control
  • Statin therapy
  • Beta-blockers 2
• Surveillance imaging at 30 days post-procedure and then annually 2

Prognosis

• Overall mortality from rAAA is estimated at 80-90%, with most patients never reaching the hospital 1
• For patients who reach the hospital and undergo repair, mortality rates have improved with endovascular approaches, with rates as low as 18.5% reported in some series 1