AAA rupture

• Rapidly expanding aneurysm

• Large diameter aneurysm

• Smoking, tobacco use

• Classic triad:

  • Hypotension due to hypovolemic shock (especially in free ruptures)

  • Sudden onset of severe, tearing back or abdominal pain with radiation to the flank, buttocks, legs, or groin

  • Painful pulsatile mass

• Grey Turner sign and/or Cullen sign (if there is an extensive retroperitoneal hematoma)

• Nausea, vomiting

• Syncope

• Hematuria

The optimal diagnostic approach depends on patient stability, available resources, and clinical suspicion. Follow local protocols if available.

• Unstable patients: The diagnosis is clinical; refer directly for operative treatment. [1][12]

• Stable patients (controversial) [1][12][16][17]

  • Consider imaging (in consultation with a vascular surgeon) provided it does not delay definitive management, for the following reasons:

    • To evaluate for alternate etiologies if the diagnosis is uncertain [1]

    • Anatomic assessment (e.g., with a thoracoabdominal CTA) to determine candidacy for EVAR and guide operative planning. [12]

  • Closely monitor patients clinically during transfer outside of critical care areas for imaging.

• CTA thorax, abdomen, and pelvis

  • Study of choice if imaging can be performed without delaying operative repair [12][17]

    • Higher detection rates for contained rupture and retroperitoneal bleeds than ultrasound

    • Allows surgeons to determine if a patient is suitable for EVAR

  • Characteristic findings

    • Sign of impending rupture: high-attenuation crescent within mural thrombus [18]

    • Signs of rupture: retroperitoneal hematoma, retroperitoneal stranding, indistinct aortic wall, extravasation of contrast

• POCUS: In an unstable patient, assume that a visible AAA on POCUS is a ruptured AAA until proven otherwise.

  • Key finding: dilatation of the aorta ≥ 3 cm

  • Other possible findings (depending on the location of the rupture)

    • Periaortic fluid

    • Free intraperitoneal fluid

    • Retroperitoneal fluid

• Laboratory findings that may be seen:

  • CBC: ↓ hemoglobin, ↓ hematocrit, ↓ red blood cell count

  • Metabolic acidosis in cases of shock

• ECG: may show ischemic changes secondary to acute blood loss

The main goal of treatment is operative repair by a vascular surgeon without delay.

• Initial management (ideally within 30 minutes)

  • Large-bore IV access

  • Start continuous monitoring and reassess regularly as patients may deteriorate rapidly.

  • Immediate hemodynamic support

    • Fluid resuscitation, or if available, blood transfusion, ideally using blood products in a 1:1:1 ratio (see “Massive transfusion”) [12][16]

    • Target: permissive hypotension (e.g., SBP 70–90 mm Hg) [1]

• Definitive treatment (ideally within 90 minutes): emergency EVAR or OSR [1][12]

Refer all patients with a suspected ruptured AAA for immediate operative evaluation.

• High mortality rate (∼ 81%) [2]

• Older age, loss of consciousness, and cardiac arrest prior to surgery are associated with high mortality.