What is the mortality rate and recommended emergency management for a ruptured abdominal aortic aneurysm?

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Ruptured Abdominal Aortic Aneurysm: Mortality and Emergency Management

Overall Mortality

The mortality rate from ruptured abdominal aortic aneurysm (rAAA) is 80-90%, with most patients dying before reaching the hospital. 1 For patients who arrive at the hospital alive, the overall mortality remains 75-90% 1. Among those who undergo surgical repair, contemporary mortality rates range from 18.5% to 50%, depending on the treatment approach and institutional protocols 1.

Mortality by Time and Treatment

  • Pre-hospital mortality: 80-90% of patients with rAAA die before reaching the hospital 1
  • Historical open repair mortality: Approximately 50% for patients who reached the hospital 1
  • Contemporary endovascular repair mortality: As low as 18.5% with an endovascular-first strategy 1
  • Time-dependent mortality for thoracic rupture: 54% at 6 hours and 76% at 24 hours after initial rupture 1

Emergency Management Algorithm

Step 1: Immediate Hemodynamic Assessment

For hemodynamically unstable patients (systolic BP <90 mmHg), proceed directly to the operating room without imaging delay. 1 Unstable patients require immediate surgical intervention as imaging will only delay life-saving treatment 2.

For hemodynamically stable patients, obtain CT angiography immediately to assess anatomy for endovascular repair feasibility. 1 This represents a Class I, Level B-R recommendation from the 2022 ACC/AHA guidelines 1.

Step 2: Permissive Hypotension Strategy

Maintain permissive hypotension (systolic BP 70-90 mmHg) to decrease bleeding rate until definitive repair. 1 This is a Class 2a, Level C-LD recommendation that reduces ongoing hemorrhage while maintaining end-organ perfusion 1.

  • Avoid aggressive fluid resuscitation and rapid infusion systems, which increase mortality 1
  • Target systolic BP 70-90 mmHg until aortic control is achieved 1

Step 3: Repair Strategy Selection

Endovascular repair (EVAR) is recommended over open repair for patients with suitable anatomy to reduce morbidity and mortality. 1 This is a Class I, Level B-R recommendation 1.

Mortality Comparison by Repair Type:

  • Endovascular repair: 18.5-23% mortality 1
  • Open surgical repair: 29-50% mortality 1
  • Long-term benefit: The IMPROVE trial demonstrated late survival benefit from endovascular repair at 3 years 1

Step 4: Anesthesia Selection for Endovascular Repair

Local anesthesia is preferred over general anesthesia for endovascular repair to reduce perioperative mortality. 1 This is a Class 2a, Level B-NR recommendation 1. General anesthesia increases hemodynamic instability and mortality risk in this critically ill population 1.

Critical Risk Factors for Mortality

Preoperative Factors Associated with Death:

  • Age ≥80 years: Significantly increases mortality risk 3, 4
  • Preoperative cardiac arrest: 80% mortality rate, though 23% of arrest patients can survive with aggressive management 4
  • Serum creatinine ≥0.15 mmol/L: Odds ratio 9.3 for mortality 3
  • Preoperative hemoglobin <9.0 g/dL: Independently predicts death 5
  • Systolic BP <90 mmHg on presentation: Major predictor of mortality 3, 5
  • Three or more medical comorbidities: Significantly increases risk 3

Intraoperative Factors:

  • Blood loss >3000 mL: Strongly associated with mortality 5
  • Glasgow Aneurysm Score >85: 88.9% mortality versus 15.9% with lower scores 6
  • Hardman Index ≥2: 81.1% mortality versus 27.3% with lower scores 6

Common Pitfalls to Avoid

Do not delay surgery for extensive preoperative optimization in unstable patients. 1 Time to hemorrhage control is the most critical factor for survival 1.

Do not aggressively resuscitate with fluids before aortic control. 1 Permissive hypotension is beneficial until the rupture is controlled 1.

Do not assume preserved wall integrity on imaging excludes rupture. 2 Contained rupture presents with intact wall on imaging but acute pain and intramural changes 2.

Do not perform open repair when endovascular repair is anatomically feasible. 1 Endovascular repair reduces mortality from approximately 33% to 19% 1.

Do not use general anesthesia for endovascular repair unless absolutely necessary. 1 Local anesthesia reduces perioperative mortality 1.

Institutional Protocol Implementation

Adopt a "rupture protocol" including early imaging, permissive hypotension, team-based organization, and immediate operating room transfer. 1 Institutions implementing endovascular-first strategies with organized rupture protocols have achieved mortality rates as low as 18.5% 1.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Diagnosing Ruptured Aortic Aneurysm

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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