Treatment of Ruptured Abdominal Aortic Aneurysm
In patients with ruptured abdominal aortic aneurysm (AAA) who have suitable anatomy, endovascular repair is recommended over open repair to reduce perioperative morbidity and mortality. 1
Initial Management
- For hemodynamically stable patients, CT imaging is recommended to evaluate whether the AAA is amenable to endovascular repair 1
- Permissive hypotension can be beneficial to decrease the rate of bleeding until definitive treatment is achieved 1
- In patients undergoing endovascular repair, local anesthesia is preferred over general anesthesia to reduce risk of perioperative mortality 1
Endovascular Repair (EVAR)
Endovascular repair is the preferred treatment option for ruptured AAA when anatomically suitable due to:
- Significantly reduced perioperative mortality compared to open repair (approximately 19-23% vs 29-33%) 1
- Lower rates of complications including stroke and permanent paraplegia 1
- Shorter procedure time and faster recovery 2
Technical considerations for EVAR in ruptured AAA:
- Ultrasound-guided percutaneous access and closure is recommended over open cutdown when suitable femoral artery anatomy is present 1
- A standardized multidisciplinary approach should be implemented, including protocols for rapid imaging and transfer to the operating room 2
- Aortic occlusion balloons may be necessary for temporary hemorrhage control 2
Open Surgical Repair
Open surgical repair remains necessary for patients with:
- Unsuitable anatomy for endovascular repair 1
- Hemodynamic instability preventing preoperative imaging 1
- Need for immediate intervention when endovascular capabilities are unavailable 1
Open repair involves:
Prognosis and Follow-up
- Overall mortality from ruptured AAA remains high (80-90%), with many patients not surviving to reach the hospital 1
- Implementation of "rupture protocols" with early imaging, permissive hypotension, and team-based organization has improved outcomes 1
- After successful repair, follow-up imaging is essential 1
- After open repair: first follow-up imaging within 1 post-operative year, then every 5 years if findings are stable 1
- After EVAR: follow-up with CT/MRI and duplex ultrasound at 1 month and 12 months post-operatively, then annual duplex ultrasound with CT/MRI every 5 years if no abnormalities are documented 1
Caveats and Special Considerations
- Patients with limited life expectancy (<2 years) may not benefit from elective AAA repair 1
- Endoleaks (persistent blood flow outside the graft but inside the aneurysm sac) are the most common complication after EVAR, requiring vigilant follow-up and possible reintervention 1
- Type I and Type III endoleaks require prompt correction to prevent rupture 1
- Chronic anticoagulation is a risk factor for reintervention, late conversion surgery, or mortality after EVAR 1