Management of Ruptured Abdominal Aortic Aneurysms

Abstract

Once seen as an unsolvable riddle, the treatment of ruptured abdominal aortic aneurysm (rAAA) has undergone a revolution over the past 20 years, with 30-day operative mortality dropping by nearly half and continuing to improve. Modern resuscitation and anesthetic techniques, endovascular surgery, improved imaging techniques, and regionalization of care have all contributed to this progress. Still, managing rAAA is a daunting task that requires a systematic approach at multiple levels of care, and management of this disease continues to evolve. This review covers the history of the management of rAAA followed by the current state of the art in prehospital care, operative intervention, and postoperative management. Although there are different algorithms to approach this disease and a multitude of technical options, this review focuses on an approach that has reduced by half the 30-day mortality of rAAA patients at Harborview Medical Center to 35.3%. Other excellent algorithms for managing rAAA exist around the country and the world; these all share a set of common principles that are highlighted. The review concludes by giving an overview of future directions for research and progress in the field. A table compares the major prognostic scoring systems for rAAA. Algorithms for managing and following up after rAAA are provided. Other figures show a hybrid operating suite, arterial access and placement of an aortic occlusion balloon, open aortic exposure and proximal vascular control, the steps of open and endovascular rAAA repair, and endoleaks after endovascular rAAA repair. This review contains 8 figures, 1 table, and 63 references.