Ruptured Abdominal Aortic Aneurysm Management (ESVS 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Ruptured AAA

   Classic triad: abdominal/back pain, hypotension, pulsatile mass

   1. ●

      Action

      Rapid Clinical Assessment

      Time-critical - mortality increases hourly

      • Classic triad present in ~50%
      • Abdominal or back pain (often sudden)
      • Hypotension or hemodynamic instability
      • Known AAA or pulsatile abdominal mass
      • Risk factors: age >65, male, smoking, HTN, family hx
      1. ⚠

         Warning

         Permissive Hypotension

         Target SBP 70-90 mmHg if conscious

         • Avoid aggressive fluid resuscitation
         • Target SBP 70-90 mmHg if patient conscious
         • Higher target if neuro symptoms
         • Prevents clot disruption
         • MTP on standby - do not over-transfuse initially
      2. ◆

         Decision

         Hemodynamic Status

         Determines imaging vs direct to OR

         1. ⚠

            Warning

            Hemodynamically Unstable

            Direct to OR - no imaging

            • Refractory hypotension despite resuscitation
            • Cardiac arrest or peri-arrest
            • Skip CT - go directly to OR
            • Aortic occlusion balloon (REBOA) if available
            • Open repair or EVAR based on surgeon preference
            1. ●

               Action

               Open Surgical Repair

               Required if EVAR not feasible

               • Midline laparotomy
               • Proximal aortic control (suprarenal or infrarenal)
               • Tube graft or bifurcated graft
               • Damage control surgery if unstable
               • Higher short-term mortality but durable
               1. ●

                  Action

                  Intraoperative Considerations

                  Critical management points

                  • Massive transfusion protocol (1:1:1)
                  • Cell salvage if available
                  • Hypothermia prevention
                  • Acidosis correction
                  • Consider leaving abdomen open (ACS risk)
                  1. ●

                     Action

                     Post-Operative ICU Care

                     Intensive monitoring for complications

                     • Abdominal compartment syndrome monitoring
                     • Colonic ischemia (10-20%) - sigmoidoscopy if concern
                     • AKI - monitor UOP, avoid nephrotoxins
                     • Cardiac events common
                     • Lower limb perfusion checks
                     1. ⚠

                        Warning

                        Abdominal Compartment Syndrome

                        Suspect if rising IAP, oliguria, resp failure

                        • Monitor bladder pressure
                        • IAP >20 mmHg with organ dysfunction = ACS
                        • Decompressive laparotomy if ACS
                        • Temporary abdominal closure
                        • Occurs in 10-30% of open repairs
                        1. ✓

                           Outcome

                           Survival

                           30-day mortality 30-50%; better with EVAR if suitable

                     2. ⚠

                        Warning

                        Colonic Ischemia

                        Common complication - high mortality

                        • Occurs in 10-20% of cases
                        • Suspect if bloody diarrhea, sepsis, metabolic acidosis
                        • Sigmoidoscopy for diagnosis
                        • Colectomy if transmural ischemia
                        • Higher risk: IMA ligation, hypotension, prior sigmoid disease
                     3. ●

                        Action

                        Acute Kidney Injury

                        Common - multifactorial

                        • Occurs in 20-40%
                        • Hypotension, contrast, suprarenal clamp
                        • Avoid nephrotoxins
                        • RRT if indicated
                        • Often recovers if patient survives
                     4. ✓

                        Outcome

                        Mortality

                        30-50% overall; 100% without intervention

            2. ●

               Action

               Endovascular Repair (EVAR)

               Recommended if anatomically suitable (Class I)

               • Lower 30-day mortality vs open (IMPROVE trial)
               • Percutaneous or cut-down access
               • Aortouniiliac + fem-fem bypass if needed
               • May need aortic occlusion balloon as bridge
               • Consider local anesthesia if unstable
         2. ●

            Action

            CT Angiography

            If hemodynamically stable - rapid protocol

            • Confirms diagnosis
            • Determines EVAR anatomic suitability
            • Shows rupture location (retroperitoneal vs free)
            • Must be performed rapidly (<30 min)
            • Do not delay if deteriorating
            1. ◆

               Decision

               EVAR Anatomically Suitable?

               Assess neck length, angulation, iliac access

               • Infrarenal neck ≥10-15mm
               • Neck angulation <60°
               • Adequate iliac access
               • Graft availability
               • Team expertise