Ruptured Abdominal Aortic Aneurysm

Educational disclaimer. This article is an educational case discussion and does not constitute medical advice. Ruptured abdominal aortic aneurysm is a life-threatening surgical emergency. Management of real patients must integrate hemodynamic status, anatomic suitability, available resources, and patient preferences, and should follow current vascular society guidelines.

Introduction

Ruptured abdominal aortic aneurysm (rAAA) is among the most time-critical vascular emergencies. Population-level case-fatality remains approximately 70–80% when out-of-hospital deaths are included, but operative mortality in patients reaching a definitive-care center has fallen to approximately 30–40% overall, and to 25–35% in centers employing an endovascular-first strategy (IMPROVE trial 3-year results, Mortality after rAAA 2025). Current guidelines from the Society for Vascular Surgery (SVS, 2018), the European Society for Vascular Surgery (ESVS, 2024), and the European Society of Cardiology (ESC, 2024) endorse management at high-volume centers with 24/7 hybrid operating-room and endovascular capability whenever logistically feasible. The case presented predates the endovascular era; the discussion below adds the contemporary algorithm.

Historical case report

Six months prior to admission, AR, a 77-year-old male, attended the University Hospital with acute urinary retention for which he had urethral catheterisation. On review in the Urological Clinic, he was found to have an AAA for which he was referred to the Surgical Clinic. On elective admission for aneurysmorrhaphy, the patient had a blood pressure of 120/80 mmHg, pulse rate of 96/min and temperature of 38.3 °C (101 °F). He had a urethral catheter draining cloudy, foul-smelling urine. In his abdomen there was an 8 cm pulsatile mass and on rectal examination his prostate gland was enlarged. All his peripheral pulses were palpable and normal.

His hemoglobin concentration was 12.4 g/dL, white cell count 17.5 × 10⁹/L, serum urea 12 mmol/L, and creatinine 110 μmol/L. His other serum electrolytes were normal. Abdominal radiographs showed curvilinear calcifications consistent with a diagnosis of AAA. Ultrasonography showed that this was infrarenal and measured 8 × 6 × 5 cm. His urine culture grew E. coli.

After one week of antibiotic therapy, the patient became afebrile with sterile urine cultures. One day later he went into shock when his aneurysm ruptured. Following rapid infusion of crystalloids and colloids, an emergency laparotomy was performed and a large retroperitoneal hematoma was found. Immediate proximal aortic control was obtained at the diaphragmatic aortic hiatus and then the neck of the infrarenal aneurysm was controlled conventionally in the infracolic compartment. The hematoma was evacuated and endoaneurysmorrhaphy performed. Intraoperative blood loss was 4.5 litres and this was replaced with blood and plasma.

Postoperatively the patient was ventilated in the Intensive Care Unit. On day five postoperatively he was transferred to the intermediate care ward with a persistent low-grade pyrexia. E. coli was grown from the aneurysmal thrombus and urine. He had a therapeutic course of appropriate antibiotics. His blood cultures remained sterile but repeat urine cultures grew Acinetobacter and Pseudomonas, resistant to all antibiotics tested. The patient was maintained on urinary antiseptics. His recovery was otherwise uncomplicated and he was discharged home 31 days after surgery with follow-up appointments to the Urological and the Surgical Clinics. When last seen, three months after discharge, the patient was awaiting admission for prostatic resection.

Modern equivalent: A patient presenting today with rupture of a known 8 × 6 × 5 cm infrarenal AAA and hemodynamic instability would be managed under a permissive hypotension strategy (target SBP 70–90 mmHg, minimal crystalloid) with immediate transfer to a hybrid operating room (NICE permissive hypotension review, Hamilton et al. 2014). If a recent contrast-enhanced CT angiogram demonstrated suitable infrarenal neck and iliac access, endovascular aneurysm repair (EVAR) would be the first-line approach per SVS 2018, ESVS 2024, and ESC 2024. Open repair would be reserved for anatomically unsuitable patients or where endovascular resources are unavailable. The growth of E. coli from the aneurysmal thrombus in this patient would today raise the diagnosis of a mycotic (infected) aneurysm, which is a special situation requiring prolonged targeted antimicrobial therapy and consideration of in situ versus extra-anatomic reconstruction.

Discussion

Epidemiology and outcomes

The incidence of rAAA has declined substantially as the century progresses in parallel with population-level smoking cessation and, in many countries, AAA screening programs for men aged 65 years and older (SVS 2018 PMG). Approximately 40–60% of patients with rupture die before reaching the hospital. Of those who do reach surgical care, contemporary 30-day operative mortality is approximately 30–40% overall, and as low as 25–35% in centers with an EVAR-first program (IMPROVE 3-year results, Mortality after rAAA 2025). Centralization to high-volume centers with endovascular capability improves outcomes and is recommended whenever transfer can be accomplished within a clinically reasonable window under permissive hypotension (ESVS 2024).

Patient selection and shared decision-making

The traditional default of offering surgery to every patient with rupture has been refined by modern frailty assessment and shared decision-making. Selected patients with severe frailty, advanced age plus major comorbidities, or clearly expressed preferences against aggressive intervention may be appropriately managed with comfort-focused care (ESVS 2024, SVS 2018). For the majority of patients, however, urgent repair remains the standard.

Preoperative care and resuscitation

Permissive hypotension is now the standard resuscitation strategy in rAAA. The goal is a systolic blood pressure of approximately 70–90 mmHg — sufficient to maintain cerebral perfusion and avoid catastrophic loss of tamponade pressure from over-resuscitation. Crystalloid use is minimized, and balanced blood-product resuscitation begins immediately (NICE permissive hypotension review, Hamilton et al.).

Activate the massive transfusion protocol with a balanced ratio of packed red blood cells, plasma, and platelets (approximately 1:1:1). Administer tranexamic acid early if local protocols permit, maintain normothermia, and replete ionized calcium based on point-of-care values. Viscoelastic testing (TEG/ROTEM) where available guides component therapy and reduces over-transfusion.

Imaging workflow:
– Hemodynamically unstable patient: bedside point-of-care ultrasound (POCUS) confirms the diagnosis within seconds; the patient proceeds directly to the operating room.
– Hemodynamically stable patient under permissive hypotension: contrast-enhanced abdominopelvic CT angiography is the standard, both to confirm rupture and to assess anatomic suitability for EVAR (SVS 2018, ESVS 2024).

Prophylactic antibiotics, nasogastric decompression, and an arterial line are appropriate. Routine preoperative heparin is avoided in patients without confirmed proximal control; selective intraoperative heparin is used during EVAR delivery.

Endovascular aneurysm repair (EVAR) — first-line where anatomy permits

EVAR is the preferred first-line modality for rAAA in anatomically suitable patients (SVS 2018, ESVS 2024, ESC 2024). The pivotal evidence base includes the IMPROVE, AJAX, and ECAR randomized trials and their long-term follow-up; the IMPROVE 3-year results demonstrated equivalent or better survival, fewer reinterventions overall, and cost-effectiveness for an EVAR-first strategy compared with open repair.

Workflow in a contemporary hybrid OR:
– Pre-induction groin preparation and percutaneous femoral access.
– Fluoroscopic-guided aortic occlusion balloon (REBOA, Zone I) deployed prophylactically or therapeutically for proximal control if the patient deteriorates at induction (REBOA in hybrid management).
– Stent-graft deployment via percutaneous or surgical femoral access; iliac branch or fenestrated/branched devices selectively employed for complex anatomy (Short/hostile neck approaches, EVAR feasibility in challenging neck).
– Completion angiography to exclude type I and III endoleaks; type II endoleaks are typically observed.

Open surgical repair

Open repair remains the standard for patients with anatomy unsuitable for EVAR (short or hostile infrarenal neck, severe iliac tortuosity/calcification, juxtarenal involvement where complex endovascular options are unavailable) and where EVAR resources are not on hand. Modern operative principles:

  • Median laparotomy or retroperitoneal approach.
  • Rapid proximal control: percutaneous femoral aortic occlusion balloon (REBOA, Zone I) is the preferred first-line technique in a hybrid OR; otherwise rapid infrarenal clamping after retroperitoneal exposure. Supraceliac clamping is reserved for situations where neck dissection is not immediately feasible. Thoracic clamping and brachial-artery Fogarty tamponade — historical techniques — are rarely required today.
  • Tube or bifurcated prosthetic graft repair; the term “endoaneurysmorrhaphy” describes the en-graft inlay technique used at open repair.
  • Selective reimplantation of a patent inferior mesenteric artery when back-bleeding or Doppler signal suggests inadequate sigmoid collateralization, to reduce the risk of ischemic colitis.

Hemostatic resuscitation and intraoperative care

Damage-control resuscitation principles apply: balanced 1:1:1 blood-product ratios, early tranexamic acid, normothermia, ionized calcium repletion, and viscoelastic-guided correction of coagulopathy. Avoid large-volume crystalloid resuscitation, which worsens dilutional coagulopathy, acidosis, and tissue edema. The historical framing of “myocardial depression from cold citrated blood” has been replaced by these contemporary principles.

Renal protection

Routine intraoperative mannitol and prophylactic furosemide are not recommended for renal protection. The current strategy comprises avoidance of prolonged hypotension, minimization of nephrotoxic contrast volume during EVAR, goal-directed resuscitation, and timely continuous renal replacement therapy (CRRT) for established acute kidney injury (SVS 2018, ESVS 2024).

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a major modern complication of rAAA repair, occurring in approximately 20% of patients after open repair and a similar or higher proportion after rEVAR — particularly when prolonged aortic balloon occlusion or large-volume resuscitation has been used (ACS and rAAA, PMC6024481). Postoperative care includes:

  • Intra-abdominal pressure monitoring via bladder pressures every 2–6 hours.
  • Recognition of intra-abdominal hypertension (IAP >12 mmHg) and ACS (sustained IAP >20 mmHg with new organ dysfunction).
  • Decompressive laparotomy with temporary abdominal closure (negative-pressure dressing) and staged closure for established ACS.

Ischemic colitis

The incidence of ischemic colitis after rAAA repair is now in the range of 5–15%, lower than the 32% reported in the 1980’s. Threshold for flexible sigmoidoscopy at 24–48 hours postoperatively should be low — bloody stools, persistent acidosis, unexplained leukocytosis, or hemodynamic deterioration warrant assessment. Full-thickness ischemia requires colectomy (SVS 2018, ESVS 2024).

Postoperative care and long-term outcomes

Postoperative management is delivered in an intensive-care environment with lung-protective ventilation, multimodal analgesia, glycemic control, early enteral feeding when feasible, and venous thromboembolism prophylaxis. Reported 60–70% mortality from postoperative AKI and respiratory failure in 1980’s series is no longer representative; modern figures are substantially lower with current ICU care (Mortality after rAAA 2025).

After successful EVAR, lifelong imaging surveillance is required — typically CTA at 1 and 12 months, then annual duplex ultrasound with selective CTA — to detect endoleak, sac enlargement, or device-related complications (SVS 2018, ESVS 2024). Long-term survival in contemporary registries is broadly comparable between EVAR and open repair beyond the perioperative period, with somewhat higher reintervention rates after EVAR offset by lower perioperative mortality.

Conclusion

Modern management of ruptured AAA centers on (1) prompt diagnosis with POCUS and CT angiography in the stable patient, (2) permissive hypotension with hemostatic resuscitation during transfer, (3) immediate transfer to a hybrid operating room at a high-volume center where possible, (4) EVAR as first-line repair in anatomically suitable patients with open repair otherwise, (5) percutaneous femoral aortic occlusion balloon (REBOA) for rapid proximal control when needed, (6) careful surveillance for and treatment of abdominal compartment syndrome, AKI, ischemic colitis, and respiratory failure, and (7) lifelong imaging surveillance after EVAR. The case described in this article — successful open repair with conventional supraceliac and infrarenal control — illustrates principles that remain valid where endovascular resources are not available. The case-specific finding of E. coli in the aneurysmal thrombus would today prompt a mycotic-aneurysm management pathway.

References

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