Part 4/Chapter 26/9-min read

Ruptured Abdominal Aortic Aneurysm/Iliac Aneurysm and Emergency Aortic Care

Suspected ruptured AAA and iliac aneurysm as a bedside diagnosis first and an imaging diagnosis second. The chapter frames triage of the unstable patient, transfer thresholds, permissive hypotension, and the open-versus-endovascular emergency repair decision.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Version 1 · Last published ·5 sections · 33 references

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Definition and presentation

Ruptured abdominal aortic is a life-threatening surgical emergency. The classic clinical presentation consists of:

  • Acute back, abdominal, or flank pain
  • Hemodynamic instability
  • A known abdominal aortic aneurysm or a detectable pulsatile abdominal mass

Diagnosis is clinical and prompts immediate triage . Activate a dedicated rupture pathway with immediate vascular, anaesthetic, theatre and CT coordination. Prompt should cover the thoracoabdominal aorta and access vessels, confirm rupture and define seal/clamp zones and access for or open repair. Many patients with circulatory instability can still undergo rapid CTA; instability alone is not a blanket contraindication. If imaging cannot be tolerated without delaying haemorrhage control, proceed directly to the operating room for control and, when feasible, intraoperative imaging. Bedside ultrasound can identify an aneurysm but cannot reliably exclude retroperitoneal rupture or provide complete EVAR planning. No fixed scan-time guarantee replaces the clinical judgement about delay.

Preoperative resuscitation and triage

Before haemorrhage control, use cautious resuscitation that maintains consciousness and organ perfusion while avoiding unnecessary pressure-driven bleeding. ESVS 2024 retains a permissive-hypotension policy with a suggested systolic range of 70–90 mmHg, but notes uncertainty and that 70 mmHg may be too low for some older patients. Escalate resuscitation for impaired consciousness or inadequate perfusion; do not force every patient down to a numerical target. Coordinate blood products and coagulation support under the major-haemorrhage protocol, and minimize time to control. This strategy ends when definitive control and postoperative organ-perfusion requirements take priority .

Contemporary emergency aortic care requires a structured institutional program. Capabilities include pre-hospital triage to a vascular center, a hybrid theatre or angiography-capable operating room, an aortic-experienced anesthetic team, and a dedicated postoperative critical-care pathway. Rural and resource-limited regions utilize explicit pre-hospital transfer pathways to route patients directly to capable centers .

Treatment strategy and decision

Observation or medical management alone is non-curative and generally fatal. Intervention is indicated for all patients in whom hemorrhage control aligns with overall care goals. For patients with prohibitive operative risk, limited life expectancy, or contrary care preferences, deliberate no-intervention and palliation is the appropriate pathway. When intervention proceeds, the choice balances anatomical suitability against hemodynamic stability and institutional capability.

In the IMPROVE trial, an endovascular-first strategy gave 30-day and 90-day mortality similar to open repair, then a mid-term survival advantage at three years (48% versus 56% mortality) with better quality of life and lower cost; by seven years mortality was about 60% in both arms, with no significant difference . Pooled registry data support that emergency endovascular aneurysm repair (EVAR) yields comparable or lower early mortality than open repair when patient anatomy and center programs are favorable . Standard anatomical selection criteria governing the choice of endovascular repair include adequate proximal neck length, acceptable neck angulation, lack of prohibitive calcification or thrombus in the seal zone, and sufficient iliofemoral access calibre.

Ruptured isolated iliac artery aneurysm follows the same logic on a smaller scale. A stable patient with adequate proximal and distal landing zones is treated endovascular-first, by covered stent across the aneurysm or an iliac branch device where the internal iliac origin must be preserved, with coil embolisation and cover of the internal iliac where it cannot. Open repair is reserved for hostile landing zones, failed access, or haemodynamic collapse that precludes imaging and endovascular deployment .

Emergency ruptured AAA pathways

  • Care goals prohibit intervention

    Preoperative action
    Provide comfort care
    Preferred pathway
    Palliation
    Citation

  • Hemodynamically tolerant

    Preoperative action
    Contrast-enhanced CTA to define anatomy
    Preferred pathway
    Endovascular-first strategy if anatomy permits; open repair if unsuitable
    Citation

  • Too unstable to tolerate rapid CTA

    Preoperative action
    Proceed directly to the operating room for immediate control and intraoperative imaging when feasible
    Preferred pathway
    EVAR or open repair according to immediately available anatomy and capability; instability alone does not exclude rapid CTA
    Citation

  • Ruptured isolated iliac aneurysm

    Preoperative action
    Contrast-enhanced CTA to define landing zones
    Preferred pathway
    Endovascular-first (covered stent or iliac branch device) if zones permit; open repair if hostile
    Citation

  • Unsuitable endovascular anatomy

    Preoperative action
    Direct to open repair planning
    Preferred pathway
    Open surgical repair
    Citation

The standard stepwise triage logic is:

  1. Immediate triage is initiated by hemodynamic instability and acute pain alongside a known aneurysm or pulsatile mass.
  2. Use permissive hypotension only while preserving consciousness and organ perfusion and expediting haemorrhage control; the suggested 70–90 mmHg range is not a mandatory target for every patient, particularly an older patient with hypoperfusion.
  3. Intervention suitability is established; patients whose goals of care or physiological status preclude survival are transitioned to a palliative pathway.
  4. Hemodynamically tolerant patients undergo contrast-enhanced CTA to evaluate endovascular suitability.
  5. Unstable patients who cannot tolerate imaging proceed directly to the operating theatre for immediate hemorrhage control.
  6. An endovascular-first strategy is executed if anatomy permits; open repair is the default when anatomy is hostile or endovascular capability is absent.

Anaesthesia and postoperative complications

For ruptured-AAA EVAR, consider local anaesthesia whenever the patient can tolerate it, with an anaesthetic team and a conversion plan; this is not a requirement for an uncooperative patient or a complex procedure needing general anaesthesia .

Intra-abdominal hypertension or abdominal compartment syndrome
  • Recognition and response
    Measure intra-abdominal pressure serially after repair; abdominal examination alone is insufficient. Sustained pressure above 20 mmHg with new organ dysfunction defines ACS. Start measures to reduce pressure and support organs, but established ACS requires urgent decompressive laparotomy.

  • Ongoing bleeding or coagulopathy

    Recognition and response
    Reassess haemodynamics, blood loss and coagulation; identify whether further operative/endovascular haemostasis is required.

  • Bowel, renal or limb ischaemia

    Recognition and response
    New abdominal findings, persistent metabolic deterioration, oliguria or loss of distal perfusion require urgent investigation and correction of the responsible vascular or systemic cause.

  • Cardiac or respiratory failure

    Recognition and response
    Continue critical-care surveillance and organ support; rupture-associated shock and treatment burden both contribute.

  • Endoleak or device/branch failure after EVAR

    Recognition and response
    Investigate new clinical deterioration promptly. In otherwise recovering patients, arrange the early postoperative CTA and subsequent risk-based surveillance plan; do not postpone suspected failure until a routine scan.

ESVS recommends pressure monitoring after both open and endovascular rupture repair and decompression for ACS. Early CTA within 30 days is part of EVAR follow-up, with timing adapted to clinical instability and renal risk . A single-centre EVAR series reported ACS in 17 of 100 included patients, with 30-day deaths in 9 of 17 with ACS versus 18 of 83 without it. This association reinforces vigilance; it does not establish a universal event rate or causal effect independent of rupture severity .

Sex disparities and counseling

Women presenting with ruptured abdominal aortic aneurysms demonstrate higher rupture-associated mortality than men in pooled registry analyses. This disparity is driven by smaller iliac access vessels, shorter proximal aneurysm necks, and later clinical presentation . The mortality gap narrows at high-volume aortic centers.

Pre-arrival counseling establishes the life-threatening nature of the emergency and the primary goal of immediate hemorrhage control. The endovascular-first approach offers comparable early outcomes and a mid-term survival and quality-of-life advantage, but remains strictly contingent on anatomical suitability and institutional resources.

Areas of controversy

The translation of the IMPROVE trial into a universal EVAR mandate remains debated. The trial evaluated an endovascular-first strategy pathway rather than isolated technical superiorities, and a substantial proportion of patients assigned to the endovascular-first arm ultimately required open repair . IMPROVE was not the only randomized trial. AJAX randomised 116 stable patients and found 30-day death or severe complications of 42% versus 47% for open repair, no significant difference . ECAR gave 30-day mortality of 18% versus 24%, also not significant . Pooled individual-patient data from all three trials showed 30-day mortality of 31.3% for the endovascular strategy versus 34.0% for open repair, with no significant difference . The mid-term survival advantage seen at three years had converged by seven years, so the durable case for an endovascular-first strategy rests on faster recovery, better early quality of life, and lower cost rather than a sustained mortality difference . Furthermore, registry data demonstrating lower early mortality for EVAR are limited by pronounced selection bias, as patients undergoing endovascular repair frequently present with more favorable anatomy and greater physiological reserve than those selected for open repair .

EVAR-only programmes and Swedish practice

Reports involving Hörer and McGreevy add experience from specialist EVAR-only programmes. The two-centre 14-year series used advanced adjuncts to treat nearly all noninfected ruptures during its EVAR-only period; it was an observational change in service strategy, not a randomized demonstration that open repair can be abandoned everywhere . Hörer and colleagues' later ACS cohort shows that total endovascular care still requires pressure monitoring and surgical decompression capability . McGreevy and colleagues'2026 chimney series reported more type Ia endoleaks after chimney repair; nonsignificant mortality differences do not prove equivalence to standard EVAR. Its abstract's overall and subgroup counts do not reconcile, so those subgroup denominators are not used here .

The Swedvasc 2025 report describes 2024 activity:81 of 114 infrarenal ruptures received endovascular repair(71.1%). The 2026 report describes 2025 activity:55 of 70 (78.6%). Thus “almost 80%” fits the later infrarenal cohort, not the earlier national all-patient denominator. These registry proportions describe use, not superiority; anatomy, case mix, referral, exclusions and open-rescue capability still matter .

Further reading

  • Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: Systematic review and meta-analysis. (2022). Diagnostic accuracy in suspected ruptured .
  • Individual-patient meta-analysis of three randomized trials comparing endovascular versus open repair for ruptured abdominal aortic aneurysm. (2015). Individual-patient synthesis of randomized ruptured-AAA repair trials.

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