Treatment of Ruptured Abdominal Aortic Aneurysm

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 is the preferred treatment option for ruptured AAA when anatomically suitable, with significantly reduced perioperative mortality compared to open repair (approximately 19-23% vs 29-33%) 3, 2
Endovascular repair has lower rates of complications including stroke and permanent paraplegia 3
Ultrasound-guided percutaneous access and closure is recommended over open cutdown when suitable femoral artery anatomy is present 1

Open surgical repair remains necessary for patients with unsuitable anatomy for endovascular repair 2
Open surgical repair is necessary for patients with hemodynamic instability preventing preoperative imaging 1
Open repair involves midline laparotomy approach, aortic cross-clamping, and replacement with a synthetic graft 2

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, with specific schedules for open repair and EVAR 4, 5
After open repair, first follow-up imaging should be within 1 post-operative year, then every 5 years if findings are stable 4
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 4

Patients with limited life expectancy (<2 years) may not benefit from elective AAA repair 4
Endoleaks are the most common complication after EVAR, requiring vigilant follow-up and possible reintervention 2
Type I and Type III endoleaks require prompt correction to prevent rupture 4
Chronic anticoagulation is a risk factor for reintervention, late conversion surgery, or mortality after EVAR 2