What is the best course of treatment for an older adult with a history of hypertension and smoking presenting with a ruptured abdominal aortic aneurysm?

Ruptured Abdominal Aortic Aneurysm: Clinical Presentation

A ruptured abdominal aortic aneurysm (AAA) presents as a life-threatening emergency with the classic triad of hypotension, severe abdominal or back pain, and a pulsatile abdominal mass, though this complete triad is present in less than half of patients. 1

Immediate Clinical Recognition

Hemodynamic Status Determines Survival:

• Overt free rupture leads to massive hemorrhage with rapid hemodynamic collapse and death, with fewer than half of patients arriving at hospital alive 2
• Contained rupture occurs when the rupture is sealed by retroperitoneal structures, allowing patients to remain hemodynamically stable temporarily 2
• Mortality reaches 54% at 6 hours and 76% at 24 hours after the initial rupture event 2

Key Presenting Symptoms

Pain Characteristics:

• Sudden onset of severe, shooting abdominal pain radiating to the back is the hallmark symptom 2, 1
• Pain may extend to the flank or groin depending on the direction of blood dissection 2
• Concurrent chest pain may occur with thoracoabdominal aneurysms 2

Cardiovascular Collapse:

• Hypotension or frank shock in the setting of acute abdominal/back pain should trigger immediate suspicion 1
• Tachycardia is nearly universal as a compensatory mechanism 1

Physical Examination Findings:

• Pulsatile abdominal mass (though physical examination has poor sensitivity and should never be relied upon to exclude AAA) 3
• Abdominal distension from hemoperitoneum 1
• Grey Turner's sign (flank ecchymosis) or Cullen's sign (periumbilical ecchymosis) may develop but are late findings 1

Rare but Critical Presentations

Atypical Manifestations to Recognize:

• Acute respiratory failure from rupture into the left hemithorax 2
• Hemoptysis from aortobronchial fistula 2
• Hematemesis from aorto-esophageal fistula 2
• These erosions into mediastinal structures are rare but immediately life-threatening 2

Risk Factor Profile

This patient's specific risk factors (hypertension and smoking history) are the two most critical modifiable risk factors for AAA development and rupture:

• Smoking is the strongest risk factor for AAA expansion and rupture 3
• Hypertension accelerates aneurysm growth 3
• Age ≥65 years and male sex are the primary non-modifiable risk factors 2

Diagnostic Urgency

Imaging must be obtained emergently but should not delay transfer to the operating room in unstable patients:

• CT angiography with non-contrast phase followed by contrast injection is the gold standard for confirming rupture and surgical planning 2
• Imaging must include the entire aorta and iliac/femoral arteries for endovascular planning 2
• Ultrasound has 95% sensitivity for detecting AAA but cannot reliably diagnose rupture 2

Treatment Decision Point

For a ruptured AAA in an older adult with hypertension and smoking history, emergency repair (either open surgical or endovascular) is mandatory regardless of aneurysm diameter, as mortality without intervention approaches 100%. 2 The choice between endovascular aneurysm repair (EVAR) and open surgery depends on hemodynamic stability, anatomic suitability, and local expertise, with emerging evidence suggesting EVAR may reduce 30-day mortality from 33% (open) to 19% (EVAR) in suitable candidates 2, 4. Local anesthesia for EVAR further reduces mortality compared to general anesthesia (15.5% vs 23.3% at 30 days) in hemodynamically stable patients 5.

Common Pitfalls

Critical errors to avoid:

• Never delay surgical consultation to obtain imaging in hemodynamically unstable patients—proceed directly to the operating room 1
• Do not rely on physical examination alone, as pulsatile mass detection has poor accuracy 3
• Recognize that contained ruptures can deteriorate to free rupture at any moment, making urgent treatment mandatory even in stable patients 2
• The closer the rupture location to the aortic valve, the higher the mortality risk 2