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Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm View in Chinese

Authors Section Editors Deputy Editor


Jeffrey Jim, MD Joseph L Mills, Sr, MD Kathryn A Collins, MD, PhD, FACS
Robert W Thompson, MD John F Eidt, MD

Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2017. | This topic last updated: Mar 08, 2017.

INTRODUCTION Symptomatic abdominal aortic aneurysm (AAA) refers to any of a number of symptoms (eg,
abdominal pain, limb ischemia) that can be attributed to the aneurysm. The presence of symptoms increases the risk for
AAA rupture, and thus, for most patients with symptomatic AAA, repair should be performed. AAA rupture can also occur
in the absence of intervening symptoms. In the United States, rupture of an abdominal aortic aneurysm occurs in
approximately 15,000 patients per year [1]. Without repair, ruptured AAA is nearly always fatal. In spite of significant
advances in intensive care unit management and surgical techniques, mortality following repair of ruptured AAA remains
high [2]. Surgical outcomes may be improved using endovascular aneurysm repair (EVAR), but aortic endografting
under emergency circumstances presents many challenges. Increasing numbers of institutions have initiated protocols
for endovascular repair of ruptured AAA with promising results in small series, but not all institutions are equipped to
treat ruptured AAAs using minimally-invasive technology.

The management of symptomatic, non-ruptured and ruptured AAA will be reviewed. The diagnosis and management of
asymptomatic AAA and general technical issues of open surgical and endovascular aneurysm repair are discussed
elsewhere. (See "Clinical features and diagnosis of abdominal aortic aneurysm" and "Open surgical repair of abdominal
aortic aneurysm" and "Endovascular repair of abdominal aortic aneurysm" and "Management of asymptomatic
abdominal aortic aneurysm", section on 'Introduction'.)

ANEURYSM TERMINOLOGY An abdominal aorta with a maximal diameter >3.0 cm is aneurysmal in most adult
patients. Abdominal aortic aneurysm (AAA) most often affects the segment of aorta below the renal arteries (figure 1);
approximately 5 percent involve the renal or visceral arteries (figure 2). Most AAAs produce no symptoms. (See
"Overview of abdominal aortic aneurysm", section on 'Definitions and aortoiliac anatomy'.)

Ruptured AAA Aortic rupture is due to the weakening of the aortic wall leading to tearing of the aortic wall,
allowing blood to escape outside the confines of the aorta. (See "Clinical features and diagnosis of abdominal
aortic aneurysm", section on 'Ruptured AAA'.)

Symptomatic (non-ruptured) AAA Symptomatic AAA refers to any of a number of symptoms (eg,
abdominal/back/flank pain, limb ischemia) that can be attributed to the aneurysm. The presence of symptoms
increases the risk for rupture [3]. (See "Clinical features and diagnosis of abdominal aortic aneurysm", section on
'Symptomatic (nonruptured) AAA'.)

INITIAL MANAGEMENT The initial management of the patient with symptomatic (non-ruptured) or ruptured AAA is
guided by the hemodynamic status. Hemodynamically unstable patients who are candidates for repair are generally
transferred directly from the emergency department to the operating room. Most patients with symptomatic (non-
ruptured) AAA are hemodynamically stable but will require admission to determine whether the AAA is the source of the
symptoms. Until the AAA can be excluded as a source of symptoms, the patient should be observed in a monitored
setting. For patients determined to have a symptomatic AAA, but for whom repair will be delayed to optimize associated
medical conditions, we admit the patient to an intensive care unit setting. (See 'Emergent versus delayed repair of
symptomatic aneurysm' below.)

Two large bore peripheral intravenous catheters should be placed in all patients (symptomatic non-ruptured or ruptured
AAA) for medication and fluid administration. In hemodynamically unstable patients with ruptured AAA, indirect evidence
from the trauma population and one observational study in patients with AAA suggest that allowing a relatively low
systolic blood pressure of 80 to 100 mmHg (permissive hypotension) may prevent further tearing of the aorta and limit
blood loss [4-6]. (See "Treatment of severe hypovolemia or hypovolemic shock in adults".)

Pain control is an important part of management. It is important to keep the patient comfortable, but consciousness
should be maintained. In patients who remain severely hypertensive despite adequate pain control, short-acting
intravenous beta-blockers (eg, esmolol) can be used to titrate the blood pressure to normal values. (See "Pain control in
the critically ill adult patient".)

Laboratory studies including complete blood count, electrolytes, blood urea nitrogen, creatinine, liver function tests,
prothrombin time, partial thromboplastin time, and a type and cross-match should be obtained. If AAA repair will be
undertaken at the hospital to which the patient presented, packed red blood cells should be placed on hold for possible
transfusion in the operating room. In patients with ruptured AAA, the patient should have at least 10 units of packed red
blood cells available for transfusion, and the blood bank should be alerted to the potential need for Fresh Frozen Plasma
(FFP) or similar products (eg, PF24), or massive transfusion. Similar to trauma patients with severe ongoing
hemorrhage, patients with ruptured AAA requiring massive transfusion may require transfusion of unmatched blood, and
may benefit from packed red blood cell: FFP ratios 2:1 rather than higher ratios. (See "Initial evaluation and
management of shock in adult trauma" and "Massive blood transfusion", section on 'Trauma' and "Clinical use of plasma
components".)

APPROACH TO AAA ASSOCIATED WITH SYMPTOMS Symptoms associated with AAA may or may not be due to
AAA rupture. A presumptive diagnosis of ruptured AAA, which is a surgical emergency, can be made in patients known
to have AAA or those with a newly diagnosed AAA who have hypotension and abdominal, flank, or back pain. Although
most patients with symptomatic (non-ruptured) AAA will require AAA repair, the timing of and approach to repair differs
depending upon the presenting symptoms which may be due to instability of the aneurysm (impending rupture,
thromboembolism), rapid expansion of the aneurysm causing abdominal discomfort, or related to inflammatory or
infected AAA causing systemic manifestations. The clinical and diagnostic features that distinguish these are discussed
in detail elsewhere. (See "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Clinical features'
and "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Diagnosis'.)

Ruptured AAA Although there are rare reports of patient survival following a contained rupture of abdominal aortic
aneurysm (AAA), in general, without repair, ruptured AAA is uniformly fatal, with death occurring usually within hours and
certainly within a week of rupture [7]. Thus, when ruptured AAA is identified, repair should be undertaken emergently to
give the patient the best chance for survival [3,8]. (See 'Initial management' above.)

Although AAA repair should be offered to most patients with ruptured AAA, some patients may be at such high risk due
to underlying comorbidities that comfort care is appropriate (See 'Decision for comfort care' below.)

Hemodynamically unstable patients with known AAA who present with classic symptoms/signs of rupture (hypotension,
flank/back pain, pulsatile mass) should be taken emergently to the operating room for immediate control of hemorrhage
and repair of the aneurysm. Efforts to obtain proximal aortic control in the operating room should not be delayed waiting
for type-specific blood components. For patients not previously known to have AAA, time may permit a focused
ultrasound exam to confirm that an aneurysm is present prior to abdominal exploration, but this is not absolutely required
(algorithm 1).
For hemodynamically stable patients suspected of having a ruptured AAA, computed tomography (CT) of the abdomen
confirms the rupture but is also important for evaluating whether an endovascular repair is feasible [9]. (See "Clinical
features and diagnosis of abdominal aortic aneurysm", section on 'Imaging symptomatic patients' and 'Aneurysm repair'
below.)

Impending rupture Some patients without overt rupture on imaging studies have clinical symptoms or other
features on CT scan that may indicate that the aneurysm is rapidly changing in configuration (rapid expansion), or at risk
for "impending" rupture. Good risk surgical candidates should generally be repaired in an urgent manner. Clinical
features are discussed in detail elsewhere. (See "Clinical features and diagnosis of abdominal aortic aneurysm", section
on 'Clinical features' and "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Ruptured versus
nonruptured AAA'.)

Symptomatic (non-ruptured) AAA Abdominal pain or other symptoms occurring in a patient known to have or newly
diagnosed with AAA can present a clinical dilemma. In surgical series, between 5 and 22 percent of AAA are
symptomatic [8,10-14]. Symptoms that may be related to AAA include abdominal pain or back pain, signs of acute
thromboembolism, and fever. In the absence of rupture, pain or other symptoms attributable to AAA may indicate rapid
expansion causing compression of adjacent structures, or an inflammatory or infected AAA [8,14-17]. In the absence of
overt or impending rupture, the symptomatic patient should be assessed to determine whether their symptoms are
related to the aneurysm, and although not well-studied, when no other cause is apparent, we agree with major society
guidelines that suggest urgent repair, provided the patient does not have comorbidities that preclude repair [3] (See
"Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Are symptoms related to AAA?' and "Clinical
features and diagnosis of abdominal aortic aneurysm", section on 'Ruptured versus nonruptured AAA'.)

Abdominal/back/flank pain Patients presenting with abdominal/back/flank pain in association with AAA should
be admitted for further evaluation and monitoring. If an alternative diagnosis cannot be definitively established,
symptoms should be presumed to be due to the AAA and a vascular surgical consultation should be obtained. The
nature of the presenting symptoms should help determine whether the AAA is the source of the symptoms or simply an
incidental finding during work-up of another disease process.

Patients identified with another obvious source (eg, urinary calculi) for their symptoms, should undergo treatment of the
other acute disease process and the AAA should be managed electively as an asymptomatic AAA. An inpatient vascular
surgical consultation should nevertheless be obtained to confirm that the symptoms are not related to the AAA and to
evaluate the need for and timing of AAA repair depending upon the resolution of the acute process. The determination of
whether to proceed with elective repair depends upon the rupture risk, which is primarily determined by aortic diameter.
The presence of very large AAA (>6.0 cm) may warrant admission even if the aneurysm is not felt to be the source of
symptoms. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Aneurysm diameter and
rupture risk' and "Management of asymptomatic abdominal aortic aneurysm", section on 'Very large aneurysm'.)

Thromboembolism Patients with symptoms and signs of acute thromboembolism should be managed according
to the severity of symptoms (acute, subacute, or chronic limb ischemia). If thromboembolism is associated with
abdominal pain, for which there is no other conceivable source, the embolus may have originated from a tear in the
aortic wall and may be a sign of overt or impending aortic rupture. In the event of AAA rupture, thrombectomy can be
performed concurrently with AAA repair.

In the presence of AAA, a full evaluation should be performed to determine the source of the thromboemboli, and should
include an electrocardiogram, echocardiogram, contrast-enhanced CT of the aorta from the aortic valve to the iliac
bifurcation, and peripheral duplex ultrasound since distal embolization can also be related to concurrent large vessel
aneurysm (eg, popliteal artery aneurysm). If the clinical evaluation does not identify an alternative source for
thromboembolism, the AAA should be presumed to be the source.

In the absence of AAA rupture, acute ischemic symptoms due to lower extremity thromboembolism from the AAA should
be managed with anticoagulation, and thrombectomy (or lysis) as needed. If a lower extremity revascularization
procedure is needed, consideration should be given to concurrent AAA repair. Under some circumstances AAA repair
can be delayed; however, the risk of recurrent thromboembolism remains until the AAA is repaired. (See "Overview of
acute arterial occlusion of the extremities (acute limb ischemia)".)

Aortic infection Patients with fever and other systemic manifestations that suggest infected aortic aneurysm
should be treated with urgent surgical debridement and vascular reconstruction. The clinical manifestations and
treatment of infected aneurysm are discussed elsewhere. (See "Overview of infected (mycotic) arterial aneurysm".)

Inflammatory aneurysm A triad of chronic abdominal pain, weight loss, and elevated erythrocyte sedimentation
rate in a patient with an AAA is highly suggestive of an inflammatory aneurysm. Patients with inflammatory aneurysms
are often more symptomatic than patients with the more typical AAAs, but the incidence of actual rupture may be lower
[18]. In patients who present with symptoms, repair should be undertaken regardless of aneurysm diameter. (See
"Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Infected versus inflammatory AAA'.)

ANEURYSM REPAIR Urgent or emergent AAA repair is generally indicated for patients with ruptured AAA and
symptomatic (non-ruptured) AAA, provided the risk for repair is not prohibitive [3,8]. The decision of whether or not to
offer repair to high-risk patients is discussed below. (See 'Decision for comfort care' below.)

Two methods of aneurysm repair are currently available: open surgery and endovascular aneurysm repair (EVAR).

Open AAA repair Open aneurysm repair involves replacement of the diseased aortic segment with a tube or
bifurcated prosthetic graft through a midline abdominal or retroperitoneal incision.

EVAR EVAR involves the placement of modular graft components delivered via the iliac or femoral arteries,
which line the aorta and exclude the aneurysm sac from the circulation.

Endovascular aneurysm repair reduces perioperative (30-day) morbidity and mortality following elective AAA repair [19-
24], and there is accumulating evidence that morbidity and mortality following repair of symptomatic [25] or ruptured AAA
may also be reduced [2,7,26-31]. A systematic review identified 23 observational studies with 7040 urgent or emergent
open (n = 6300) or endovascular (n = 740) AAA repairs in patients with symptomatic (non-ruptured) or ruptured AAA
[25]. Emergency EVAR was associated with a significantly reduced perioperative (30-day) mortality risk relative to open
repair (pooled odds ratio [OR] 0.62, 95% CI 0.52-0.75).

To perform emergent endovascular AAA repair, the patient's aneurysm must meet anatomic criteria for EVAR and the
institution must have a defined program for emergency endovascular surgery. Abdominal CT, which is obtained in
hemodynamically stable patients, will determine whether the patient with symptomatic (non-ruptured) or ruptured AAA is
anatomically suited to endovascular aneurysm repair (EVAR). Although up to 70 percent of patients may be candidates
for EVAR, ruptured AAA is more often repaired with open surgical techniques, due to the limited number of centers
available to perform emergency EVAR. Transfer to a vascular center is appropriate for hemodynamically stable patients
who are anatomically suited to EVAR, particularly if the risk for open repair is high. (See 'Decision for patient transfer'
below and 'Risk assessment' below.)

The anatomic requirements for endovascular repair for non-ruptured and ruptured AAA are discussed elsewhere. (See
"Endovascular repair of abdominal aortic aneurysm", section on 'Anatomic suitability' and "Surgical and endovascular
repair of ruptured abdominal aortic aneurysm", section on 'Criteria for endovascular repair'.)

Risk assessment The general assessment of perioperative risk for urgent/emergent repair of abdominal aortic
aneurysm is similar to that of elective AAA repair; however, the urgency of the clinical situation often precludes a
comprehensive evaluation. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Medical risk
assessment'.)

There have been many attempts to quantify the mortality risk associated with ruptured AAA. Various prediction models
are available, but, unfortunately, no one system or variable has proven to be reliable in predicting mortality with certainty
nor reliably support the decision to withhold intervention [32,33]. Factors that are associated with increased mortality
following open repair of ruptured AAA include hypotension with a systolic blood pressure <80 mmHg, advanced age
(>80 years), cardiac arrest, loss of consciousness, creatinine >1.3 on admission, ischemic heart disease, female sex,
and hemoglobin <9.0 on admission [2,34-44]. There are no equivalent studies assessing preoperative risk factors and
endovascular aneurysm repair of ruptured AAA. One risk prediction model based upon a population of United States
Medicare beneficiaries (ie, >65 years of age), found that mortality following elective AAA repair is predicted by
comorbidities, gender, and age with no differential predictors between open or endovascular repair [45].

For patients with several prognostic factors for poor outcome, the incidence of serious morbidity, such as dialysis
dependence, colonic ischemia, and myocardial infarction, is high and the need for surgery related to a complication is
also high. The presence of >3 prognostic factors increases the likelihood that the patient will require extended care. For
the patient who is older than 80, with renal dysfunction, loss of consciousness, and hemoglobin <9, the chance of
survival following open repair of ruptured AAA is almost zero [33]. The presence of multiple risk factors for poor outcome
in a patient of advanced age, especially those with a "Do Not Resuscitate" advanced directive or a history of AAA repair
refusal should lead to consideration for comfort care. (See 'Decision for comfort care' below.)

Emergent versus delayed repair of symptomatic aneurysm The timing of AAA repair for hemodynamically stable
patients with symptomatic (non-ruptured) AAA remains a clinical challenge. Some patients may benefit from optimization
of their medical status prior to repair; however, a definitive recommendation that would suit every clinical situation is not
possible.

Several retrospective case series comparing open AAA repair under elective versus emergent circumstances for
symptomatic (non-ruptured) AAA have found significantly higher overall rates of perioperative morbidity and mortality for
emergent compared with urgent repair (overall 18 to 26 percent versus 4 to 5 percent) [8,46,47]. Another series found no
deaths from rupture in patients with symptomatic AAA whose operations were delayed and performed semi-electively
[14]. The potential impact of endovascular repair in this subset of patients is unknown, but is unlikely to alter the need for
preoperative medical optimization that appears to be beneficial for some patients.

MORBIDITY AND MORTALITY For symptomatic, non-ruptured AAAs, perioperative mortality rates are similar to
those of elective repair; however, the rates of postoperative complications and late survival are intermediate compared
with elective or ruptured AAA repair [48]. (See "Management of asymptomatic abdominal aortic aneurysm", section on
'AAA repair' and "Endovascular repair of abdominal aortic aneurysm", section on 'Perioperative morbidity and mortality'
and "Open surgical repair of abdominal aortic aneurysm", section on 'Morbidity and mortality'.)

The mortality associated with ruptured AAA may be as high as 90 percent when patients who die at home or upon arrival
to the hospital are taken into account. In spite of obvious improvements in pre-hospital care, cardiovascular anesthesia,
and critical care, surgical mortality following open repair of ruptured AAA has changed very little, remaining at
approximately 30 to 50 percent [49,50]. Although endovascular aneurysm repair may improve survival following AAA
rupture, this has not been definitively established. The complications of aneurysm repair and mortality associated with
ruptured AAA are discussed in detail elsewhere. (See "Surgical and endovascular repair of ruptured abdominal aortic
aneurysm", section on 'Complications' and "Surgical and endovascular repair of ruptured abdominal aortic aneurysm",
section on 'Mortality'.)

DECISION FOR PATIENT TRANSFER Patients with AAA who require emergent or urgent aortic surgery for ruptured
or symptomatic (non-ruptured) AAA should be treated at a facility where surgical expertise and/or the perioperative
resources necessary for major aortic surgery are available (eg, operating room personnel, an appropriately-trained
surgeon, perioperative intensive care) [51]. For patients who present to a facility where these are not available, transfer
to a vascular center with higher levels of hospital resources (such as number of physicians, nurses, and critical care
beds) is appropriate and may result in lower mortality [52]. In a study of 35,367 patients in England in the United States,
the lowest mortality for ruptured AAA was seen in teaching hospitals with larger bed capacities and doing a greater
proportion of cases with EVAR [53].

Improved outcomes for open surgical repair of ruptured AAA are correlated with surgeon experience with a higher
annual caseload of open aneurysm repair per year (non-ruptured and ruptured) correlating with improved outcomes [54].
The shift toward endovascular therapies has reduced the exposure of the vascular surgeon-in-training to open surgical
repair of AAA. As a result, the number of qualified surgeons in the community experienced with open repair of ruptured
AAA is declining [55]. If an appropriate level of surgical care is not available at the institution to which the patient initially
presented, the patient should be transferred [51]. If transfer is chosen, the patient and their family should be informed of
the potential risk of deterioration during transfer, and the transfer should be accomplished as quickly as possible.

Patients who have a high-risk for open AAA repair may be candidates for endovascular repair. However, for
endovascular repair to be undertaken, in addition to having appropriate hospital personnel in place, the institution must
have systems in place to support the endeavor. Resources that are needed include:

Rapid availability of high-quality computed tomography

Availability of trained support staff (nursing, scrub technicians, radiology technologists, anesthesia)

Stock of available endovascular prostheses in a wide range of sizes, which are replenished continuously

Available vascular surgeon appropriately-trained in advanced endovascular techniques

For most small hospitals and low-volume facilities, these requirements cannot be met. If an institution is not able to
perform emergency EVAR, an alternative approach is to provide open repair for hemodynamically unstable patients and
transfer for hemodynamically stable patients to an appropriate vascular center.

DECISION FOR COMFORT CARE Some patients may refuse repair of a ruptured AAA, or are such poor candidates
for repair that they are not likely to survive or have a meaningful quality of life even if they recover from the procedure.
Although it remains disputed whether endovascular repair decreases mortality in patients with ruptured AAA, patients
who have factors associated with a poor prognosis for open AAA repair may have lower rates of morbidity and mortality
following EVAR for ruptured AAA, when repair is chosen. (See 'Risk assessment' above.)

A decision must be made according to the wishes of the patient (if known) and family whether to proceed with repair or
provide comfort measures. Patients who will not undergo repair are kept pain-free and allowed to expire. In one study of
21 patients, the average time to death following ruptured AAA without repair was seven hours [56]. In another study of
57 patients with ruptured AAA who did not undergo surgical intervention, the median survival was 2.2 hours [57].
However, the survival after two hours was significantly different for patients who had shock or required cardiopulmonary
resuscitation (13 percent) compared with those who were stable but not treated due to patient decision, comorbidity,
age, or anatomic considerations. (See "Pain assessment and management in the last weeks of life".)

SUMMARY AND RECOMMENDATIONS

Symptomatic abdominal aortic aneurysm (AAA) refers to any of a number of symptoms (eg, abdominal/back/flank
pain, limb ischemia) that can be attributed to the aneurysm. In the absence of overt rupture (defined as aortic wall
disruption leading to escape of blood outside the confines of the aorta), the presence of symptoms increases the
risk for AAA rupture. AAA rupture can also occur in the absence of any intervening symptoms. Without repair,
ruptured AAA is nearly uniformly fatal. Of the 50 percent of patients with ruptured AAA who reach the hospital for
treatment, between 30 and 50 percent will die in the hospital in spite of significant advances in intensive care unit
management and surgical techniques. (See 'Introduction' above and 'Morbidity and mortality' above.)

Initial management of patients with symptomatic (non-ruptured) and ruptured AAA includes the placement of large
bore peripheral intravenous catheters for medication and fluid administration, pain management, and preparation
for surgery. For patients with ruptured AAA, we suggest maintaining the systolic blood pressure between 80 and
100 mmHg (permissive hypotension) rather than at higher levels prior to repair (Grade 2C). Permissive
hypotension may minimize further tearing of the aorta and reduce blood loss. (See 'Initial management' above.)

Although there are rare reports of patient survival following ruptured AAA without repair, in general, expectant
management of ruptured AAA is nearly uniformly fatal. Thus, when ruptured AAA is identified, repair should be
undertaken emergently to give the patient the best chance for survival. (See 'Ruptured AAA' above.)

For patients with symptomatic (non-ruptured) AAA of any size or configuration who do not have a prohibitive risk
for repair, we agree with major society guidelines that suggest urgent AAA repair (open or endovascular), rather
than no repair (Grade 2C). In the absence of rupture, symptoms may indicate that the aneurysm is rapidly
changing, increasing the risk of rupture. Symptoms may include abdominal/back/flank pain, signs of
thromboembolism, or systemic symptoms related to infected or inflammatory aneurysm. (See 'Symptomatic (non-
ruptured) AAA' above.)

Hemodynamically unstable patients with known AAA who present with classic symptoms/signs of rupture
(hypotension, flank/back pain, pulsatile mass) should be taken directly to the operating room for immediate control
of hemorrhage and repair of the aneurysm (algorithm 1). Efforts to obtain proximal aortic control in the operating
room should not be delayed waiting for type-specific blood components. For hemodynamically unstable patients
not previously known to have AAA, time may permit a focused ultrasound exam to confirm that an aneurysm is
present prior to abdominal exploration, but this is not absolutely required. For patients with symptomatic (non-
ruptured) or ruptured AAA who are hemodynamically stable, computed tomography (CT) of the abdomen should
be obtained to evaluate whether an endovascular repair is feasible. (See 'Ruptured AAA' above and "Clinical
features and diagnosis of abdominal aortic aneurysm", section on 'Imaging symptomatic patients'.)

Although many factors are associated with poor outcomes following repair of ruptured AAA, no scoring system or
variable has proven reliable in predicting mortality of ruptured AAA with certainty. Factors on admission that are
associated with increased mortality following open repair of ruptured AAA include hypotension, elevated creatinine,
low hematocrit, advanced age, and cardiac arrest. For older patients (>80 years) with multiple risk factors in whom
EVAR is not feasible, comfort care should be discussed with the patient and/or family as a possible care option.
(See 'Risk assessment' above and 'Decision for comfort care' above.)

For patients with ruptured AAA, where appropriate facilities, personnel, equipment, and expertise are available for
endovascular aneurysm repair (EVAR), we suggest EVAR rather than open AAA repair, provided it is anatomically
feasible (Grade 2C). In appropriately selected patients, endovascular repair of ruptured AAA appears to be
associated with lower perioperative (30-day) morbidity and mortality. For patients with symptomatic but non-
ruptured AAA who have multiple risk factors for poor prognosis, we also suggest EVAR rather than open repair
(Grade 2C). Where endovascular aneurysm repair for emergency AAA repair is not an option (eg, not anatomically
feasible, lack of facilities or expertise), open repair at the initial facility by a surgeon experienced with aortic surgery
is appropriate. If no such surgeon is available, or the patient is a poor candidate for open repair, transfer to a
vascular center is appropriate. (See 'Decision for patient transfer' above and 'Aneurysm repair' above and "Surgical
and endovascular repair of ruptured abdominal aortic aneurysm", section on 'Open surgical versus endovascular
repair'.)

ACKNOWLEDGMENT We are saddened by the death of Emile R Mohler, III, MD, who passed away in October 2017.
UpToDate wishes to acknowledge Dr. Mohler's work as our Section Editor for Vascular Medicine.

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Topic 15191 Version 14.0

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