Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm
- Jeffrey Jim, MD
Jeffrey Jim, MD
- Associate 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
- 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'.)
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- 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