Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm
- Jeffrey Jim, MD
Jeffrey Jim, MD
- Assistant Professor of Surgery
- Washington University School of Medicine
- Robert W Thompson, MD
Robert W Thompson, MD
- Professor of Surgery, Radiology, Cell Biology and Physiology
- Washington University School of Medicine
- Department of Surgery
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular Surgery
- Professor of Surgery
- University of Arizona Health Sciences Center
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
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 about 15,000 patients per year . 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 . 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'.)
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 . (See "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Symptomatic (nonruptured) AAA'.)
- http://hcupnet.ahrq.gov/HCUPnet (Accessed on May 11, 2012).
- Dillavou ED, Muluk SC, Makaroun MS. A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women? J Vasc Surg 2006; 43:230.
- Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2.
- IMPROVE Trial, Powell JT, Thompson SG, et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial--ISRCTN 48334791 IMPROVE trialists. Acta Chir Belg 2009; 109:678.
- Reimerink JJ, Hoornweg LL, Vahl AC, et al. Controlled hypotension in patients suspected of a ruptured abdominal aortic aneurysm: feasibility during transport by ambulance services and possible harm. Eur J Vasc Endovasc Surg 2010; 40:54.
- Dick F, Erdoes G, Opfermann P, et al. Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm. J Vasc Surg 2013; 57:943.
- Lesperance K, Andersen C, Singh N, et al. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective. J Vasc Surg 2008; 47:1165.
- Sullivan CA, Rohrer MJ, Cutler BS. Clinical management of the symptomatic but unruptured abdominal aortic aneurysm. J Vasc Surg 1990; 11:799.
- Siegel CL, Cohan RH, Korobkin M, et al. Abdominal aortic aneurysm morphology: CT features in patients with ruptured and nonruptured aneurysms. AJR Am J Roentgenol 1994; 163:1123.
- Nevala T, Perälä J, Aho P, et al. Outcome of symptomatic, unruptured abdominal aortic aneurysms after endovascular repair with the Zenith stent-graft system. Scand Cardiovasc J 2008; 42:178.
- Franks S, Lloyd G, Fishwick G, et al. Endovascular treatment of ruptured and symptomatic abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2006; 31:345.
- Antonello M, Lepidi S, Kechagias A, et al. Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2007; 33:272.
- Shifrin EG, Pizov R, Perel A, et al. Urgent abdominal aortic aneurysm repair in patients over the age 80. J Cardiovasc Surg (Torino) 1987; 28:167.
- Cambria RA, Gloviczki P, Stanson AW, et al. Symptomatic, nonruptured abdominal aortic aneurysms: are emergent operations necessary? Ann Vasc Surg 1994; 8:121.
- Adam DJ, Haggart PC, Ludlam CA, Bradbury AW. Hemostatic markers before operation in patients with acutely symptomatic nonruptured and ruptured infrarenal abdominal aortic aneurysm. J Vasc Surg 2002; 35:661.
- Soisalon-Soininen S, Salo JA, Perhoniemi V, Mattila S. Emergency surgery of non-ruptured abdominal aortic aneurysm. Ann Chir Gynaecol 1999; 88:38.
- Leo E, Biancari F, Kechagias A, et al. Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature. Scand Cardiovasc J 2005; 39:91.
- Lindblad B, Almgren B, Bergqvist D, et al. Abdominal aortic aneurysm with perianeurysmal fibrosis: experience from 11 Swedish vascular centers. J Vasc Surg 1991; 13:231.
- Mehta M, Byrne J, Darling RC 3rd, et al. Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. J Vasc Surg 2013; 57:368.
- Nedeau AE, Pomposelli FB, Hamdan AD, et al. Endovascular vs open repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2012; 56:15.
- Alsac JM, Kobeiter H, Becquemin JP, Desgranges P. Endovascular repair for ruptured AAA: a literature review. Acta Chir Belg 2005; 105:134.
- Brady AR, Fowkes FG, Greenhalgh RM, et al. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 2000; 87:742.
- Dillavou ED, Muluk SC, Makaroun MS. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg 2006; 43:446.
- Lee WA, Carter JW, Upchurch G, et al. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg 2004; 39:491.
- Sadat U, Boyle JR, Walsh SR, et al. Endovascular vs open repair of acute abdominal aortic aneurysms--a systematic review and meta-analysis. J Vasc Surg 2008; 48:227.
- Veith FJ, Lachat M, Mayer D, et al. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009; 250:818.
- Starnes BW, Quiroga E, Hutter C, et al. Management of ruptured abdominal aortic aneurysm in the endovascular era. J Vasc Surg 2010; 51:9.
- McPhee J, Eslami MH, Arous EJ, et al. Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): a significant survival benefit over open repair is independently associated with increased institutional volume. J Vasc Surg 2009; 49:817.
- Chagpar RB, Harris JR, Lawlor DK, et al. Early mortality following endovascular versus open repair of ruptured abdominal aortic aneurysms. Vasc Endovascular Surg 2010; 44:645.
- Mureebe L, Egorova N, Giacovelli JK, et al. National trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2008; 48:1101.
- Davenport DL, O'Keeffe SD, Minion DJ, et al. Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010; 51:305.
- Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg 2008; 47:222.
- Johnston KW. Ruptured abdominal aortic aneurysm: six-year follow-up results of a multicenter prospective study. Canadian Society for Vascular Surgery Aneurysm Study Group. J Vasc Surg 1994; 19:888.
- Sarac TP, Bannazadeh M, Rowan AF, et al. Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms. Ann Vasc Surg 2011; 25:461.
- Biancari F, Venermo M, Finnish Arterial Disease Investigators. Open repair of ruptured abdominal aortic aneurysm in patients aged 80 years and older. Br J Surg 2011; 98:1713.
- Biancari F, Leo E, Ylönen K, et al. Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm. Br J Surg 2003; 90:838.
- Biancari F, Hobo R, Juvonen T. Glasgow Aneurysm Score predicts survival after endovascular stenting of abdominal aortic aneurysm in patients from the EUROSTAR registry. Br J Surg 2006; 93:191.
- Korhonen SJ, Ylönen K, Biancari F, et al. Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm. Br J Surg 2004; 91:1449.
- Karkos CD, Sutton AJ, Bown MJ, Sayers RD. A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2011; 42:775.
- Pol RA, Reijnen MM, Zeebregts CJ. Outcome after open repair of ruptured abdominal aortic aneurysm in patients >80 years old: a systematic review and meta-analysis. World J Surg 2011; 35:2575.
- Opfermann P, von Allmen R, Diehm N, et al. Repair of ruptured abdominal aortic aneurysm in octogenarians. Eur J Vasc Endovasc Surg 2011; 42:475.
- Scarcello E, Ferrari M, Rossi G, et al. A new preoperative predictor of outcome in ruptured abdominal aortic aneurysms: the time before shock (TBS). Ann Vasc Surg 2010; 24:315.
- McPhee JT, Hill JS, Eslami MH. The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004. J Vasc Surg 2007; 45:891.
- Giles KA, Schermerhorn ML, O'Malley AJ, et al. Risk prediction for perioperative mortality of endovascular vs open repair of abdominal aortic aneurysms using the Medicare population. J Vasc Surg 2009; 50:256.
- Haug ES, Romundstad P, Aadahl P, Myhre HO. Emergency non-ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2004; 28:612.
- Tambyraja AL, Raza Z, Stuart WP, et al. Does immediate operation for symptomatic non-ruptured abdominal aortic aneurysm compromise outcome? Eur J Vasc Endovasc Surg 2004; 28:543.
- De Martino RR, Nolan BW, Goodney PP, et al. Outcomes of symptomatic abdominal aortic aneurysm repair. J Vasc Surg 2010; 52:5.
- Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg 2002; 89:714.
- Hoornweg LL, Storm-Versloot MN, Ubbink DT, et al. Meta analysis on mortality of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008; 35:558.
- Maybury RS, Chang DC, Freischlag JA. Rural hospitals face a higher burden of ruptured abdominal aortic aneurysm and are more likely to transfer patients for emergent repair. J Am Coll Surg 2011; 212:1061.
- Cho JS, Kim JY, Rhee RY, et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. J Vasc Surg 2008; 48:10.
- Boyle JR, Gibbs PJ, Kruger A, et al. Existing delays following the presentation of ruptured abdominal aortic aneurysm allow sufficient time to assess patients for endovascular repair. Eur J Vasc Endovasc Surg 2005; 29:505.
- ANEURYSM TERMINOLOGY
- INITIAL MANAGEMENT
- APPROACH TO AAA ASSOCIATED WITH SYMPTOMS
- Ruptured AAA
- - Impending rupture
- Symptomatic (non-ruptured) AAA
- - Abdominal/back/flank pain
- - Thromboembolism
- - Aortic infection
- - Inflammatory aneurysm
- ANEURYSM REPAIR
- Risk assessment
- Emergent versus delayed repair of symptomatic aneurysm
- MORBIDITY AND MORTALITY
- DECISION FOR PATIENT TRANSFER
- DECISION FOR COMFORT CARE
- SUMMARY AND RECOMMENDATIONS