What is the management approach for a ruptured abdominal aortic aneurysm (AAA)?

Management of Ruptured Abdominal Aortic Aneurysm

For hemodynamically stable patients with ruptured AAA and suitable anatomy, endovascular repair (EVAR) is the definitive treatment of choice over open repair, reducing 30-day mortality from 34% to 21%. 1

Immediate Stabilization and Diagnostic Approach

Hemodynamic Management

• Implement permissive hypotension to decrease bleeding rate until definitive repair is achieved 1
• Avoid aggressive fluid resuscitation that increases blood pressure and exacerbates hemorrhage 1
• The goal is maintaining organ perfusion while minimizing ongoing blood loss 1

Imaging Strategy Based on Hemodynamic Status

• If hemodynamically stable: Obtain CT imaging immediately to determine if the anatomy is suitable for endovascular repair 1
• If hemodynamically unstable: Proceed directly to the operating room without imaging, as these patients cannot tolerate delays 1
• The IMPROVE trial demonstrated that obtaining preoperative CT in stable patients does not increase mortality risk and enables optimal treatment selection 1

Critical pitfall: Do not obtain additional dedicated CTA if the initial CT scan provides sufficient anatomic information to determine EVAR feasibility—time is critical and unnecessary imaging delays definitive treatment 1

Definitive Repair Strategy

Endovascular Repair (Preferred When Anatomically Suitable)

• EVAR reduces 30-day mortality to 21% compared to 34% with open repair in propensity-matched registry data 1
• Long-term survival benefit persists: between 90 days and 3 years, EVAR demonstrates superior survival (hazard ratio 0.57,95% CI 0.36-0.9) 1
• Use local anesthesia rather than general anesthesia when performing EVAR to further reduce perioperative mortality 1
• Mortality rates with EVAR have declined to as low as 18.5% in centers using rupture protocols with an endovascular-first strategy 1

Open Surgical Repair (When EVAR Not Feasible)

• Required for patients with unsuitable anatomy for endovascular repair 1, 2
• Necessary for hemodynamically unstable patients who cannot undergo preoperative imaging 1
• Involves midline laparotomy, proximal aortic control, and synthetic graft replacement 2
• Historical mortality for open repair of ruptured AAA is approximately 50%, though modern series show improvement 1

Important consideration: Early randomized trials showed no early survival benefit for EVAR, but these trials excluded hemodynamically unstable patients who likely benefit most from the endovascular approach 1

Institutional Rupture Protocols

Implement team-based "rupture protocols" that include: 1

• Early imaging for stable patients
• Permissive hypotension strategy
• Endovascular balloon occlusion under fluoroscopy to control hemorrhage
• Immediate operating room availability with coordinated team response

These protocols have reduced mortality rates substantially in observational series 1

Post-Repair Surveillance

After EVAR

• CT/MRI and duplex ultrasound at 1 month and 12 months post-operatively 2
• Annual duplex ultrasound with CT/MRI every 5 years if no abnormalities documented 2
• Type I and Type III endoleaks require prompt correction to prevent rupture 2, 3

After Open Repair

• First follow-up imaging within 1 postoperative year 2
• Subsequent imaging every 5 years if findings are stable 2

Prognostic Reality

• Overall mortality from ruptured AAA remains 80-90%, with most patients dying before reaching the hospital 1, 2
• For patients reaching the hospital, modern endovascular-first strategies have reduced mortality to approximately 19-23% 2
• Preoperative shock, massive intraoperative blood loss, and postoperative respiratory or renal complications significantly influence mortality 4