Ruptured AAA

Mohamad Taha, MD
Consultant of Vascular Surgery
Mataria Teaching Hospital 2019
No emergency in vascular surgery is more acute
or lethal than the rupture of an abdominal aortic
aneurysm (AAA).

About half of all persons with rAAA die before

reaching a hospital, 25% of those who do reach
a hospital alive die before treatment, and 40% of
those who undergo surgery die; thus, the overall
mortality of rAAA is roughly 80%.
Once rupture occurs, patient survival
depends on prompt surgical intervention
to control hemorrhage and aggressive and
often complex postoperative critical care
management.

Many centers began applying EVAR

technique to selected patients presenting
with rupture.
 Diagnosis
The identification of a patient presenting with ruptured AAA is
first and foremost a clinical diagnosis based on a careful history
and physical examination.

The most common presentation of ruptured infra-renal AAA is

the classical triad of: sudden and sever back pain with or without
abdominal pain, hypotension and/or syncope and pulsatile
abdominal mass. However, such presentation is only seen in
25-50 % of the population and some may present with entirely
different presentation.

Patients presenting with this triadf need no other evaluation and

should proceed directly to repair.
 Common and uncommon
presentation of ruptured AAA.
Plain abdominal radiographs (KUB) continue
to be performed on the patients with
abdominal pain and can be important in
guiding the investigations in the emergency
room.

Aortic wall calcifications on the KUB confirm

the presence of AAA in 75% of the patients.

Moreover, loss of a psoas shadow may be

apparent in the presence of rupture.
In some patients the diagnosis may be far less obvious,
presenting without hemodynamic instability so it is
important to have a high index of suspicion for the
diagnosis in any patient over the age of 50 presenting
with back, abdomen, or flank pain.

When the physical examination is unclear an

abdominal ultrasound can be used as a quick adjunct
to the history and physical examination.

Ultrasound is sensitive in identifying aneurysms and

can be used to evaluate the aorta rapidly. but is poor in
determining the presence of aortic rupture.
In stable patients where the diagnosis
is suspected, a computed tomography
(CT) scan is the most accurate method
of detecting a ruptured AAA.

Modern CT scanners can rapidly

provide the needed anatomic
information for the evaluation of
patients for endovascular options.
Typical appearance of a ruptured infrarenal aortic aneurysm
on a contrast enhanced computed tomographic scan. Note
the large hematoma to the right of the aorta, obscuring the
right psoas muscle and displacing the bowel anteriorly.

CT Angio.
Plain CT
Plain CT
Rapid transport of the patient to the operating room
must be immediately undertaken.

Unnecessary time can be wasted in an ill advised attempt

at resuscitation of the patient prior to transport to the
operating room.

Resuscitation by permissive hypotension to minimize

ongoing hemorrhage.

Hypothermia is a common problem in these patients and

should be prevented by warming the room and covering
the patient with a heated air circulating blanket.
 SURGICAL
TECHNIQUE
Open Repair
General endotracheal anesthesia should not be
initiated until the operative field has been
sterilely prepped and draped, just before the skin
incision.

General anesthesia relaxes the muscles of the

abdominal wall; sudden reduction of the
abdominal pressure can convert a retroperitoneal
perforation into an intraperitoneal hemorrhage,
immediately causing shock.
The immediate goal of the surgeon is to
gain proximal control of the aorta.

If the patient's hemodynamic status

deteriorates rapidly when the
tamponade effect of the abdominal
wall is lost with laparotomy, the
surgeon can compress the aorta against
the spine above the celiac artery.
(A) Method of manually compressing the supraceliac
aorta against the spine for temporary proximal control.
Alternatively; a sponge stick. or (B) a commercially
available aortic compressor can be used.
In the case of an uncontained rupture, a foley catheter can be
inflated in the suprarenal aorta to gain rapid proximal control.
Overinflation can rupture the aorta.
 Some perform intraoperative hemostasis with
transfemoral or transbrachial balloon occlusion

Endoaortic balloon positioned just above the celiac trunk

Most ruptures occur posterior and lateral to the
anterior surface of the aorta. In those cases the
infrarenal neck of the aneurysm may be relatively
free of hematoma and can be approached in
a manner similar to that for elective aneurysm repair.

The transverse colon is retracted superiorly and the

small bowel eviscerated or retracted to the right side
of the abdomen.

The retroperitoneum is incised over the aneurysm

and the duodenum mobilized to the right by incising
the ligament of Treitz.
All dissection should be directed superiorly, toward
the neck of the aneurysm. Extending the dissection
distally into the hematoma prior to gaining
proximal control should be avoided.

If the region of the neck of the aneurysm is

obscured by hematoma. much of the dissection and
exposure can be done bluntly with surgeon's fingers
avoiding sharp injury to adjacent structures.

Dissection proceeds superiorly until the normal

aortic wall is encountered. Usually this will be close
to the point where the left renal vein crosses the
anterior wall of the aorta.
Proximal control
The left renal vein can be retracted superiorly slightly while
the surgeon establishes a space on the lateral surfaces of the
aorta with finger dissection in a longitudinal direction to
permit the placement of the aortic clamp.

Almost always the segment of aorta under the left renal vein
is relatively normal in infrarenal aneurysms.

Once the aorta is clamped, the aorta is opened longitudinally

and fully exposed. With the hematoma and aneurysm sack
decompressed, the iliac arteries can be more easily exposed
and clamped.

Care must be taken to avoid injury to the adjacent vena cava

and common iliac veins.
If the iliac vessels are encased in hematoma, it is
best to make no attempt to expose them at all,
avoiding injury to both venous structures and
the ureter.

Control can be achieved with a large-diameter

embolectomy balloon catheter or Foley catheter
placed into the lumen of the common iliac artery
from within the aorta.

In some cases, backbleeding from the illac

arteries is so limited that no control is necessary.
 Control of the
supraceliac aorta
In the cases of severe hypotension or uncontrolled
bleeding from intraperitoneal rupture. Or whenever the
surgeon feels that the extent of the hematoma or the
shape or size of the aneurysm makes conventional
exposure too difficult or impossible, control of the
supraceliac aorta can be obtained.

Many surgeons prefer to initially control the supraceliac

aorta in all cases of aortic rupture.

It is preferable to initially gain control of the infrarenal

aorta whenever possible, reserving supraceliac control
for selected circumstances.
The gastrohepatic omentum is divided longitudinally,
the lesser omental sac entered, and the aorta
digitally mobilized at the diaphragmatic crus.
 This may be helpful in proximal aortic control during contained infrarenal aortic
rupture when blood staining and hematoma obliterates the retroperitoneal anatomy.
On rare occasions gaining proximal control at any
level in the abdomen may be so difficult that
left thoracotomy and aortic cross-clamping just
above the diaphragm may be the only solution.
Repair of the aneurysm is generally carried out
in a fashion similar to elective repair. Tube graft
repair is preferable whenever possible since it is
simpler and decreases operative time.
 Declamping Shock

Restoration of flow to the extremities

should be done carefully and
sequentially to avoid severe
hypotension (central hypovolemia
syndrome or declamping Shock).
Good communication with the anesthesia team is
critical. An assistant vigorously compresses the
femoral arteries in the groin with a closed fist to
initially direct most blood flow into the pelvic
vessels to minimize both hypotension and emboli
to the extremities.

If the patient maintains a blood pressure of at

least 90 mm. femoral compression is gradually
released. Any significant hypotension is corrected
with appropriate volume replacement, judicious
use of vasopressors or reclamping of the graft.
Once full flow has been established to one
extremity, flow is restored to the second limb.

The left colon is examined for evidence of

ischemic changes.

Primary abdominal closure has been the most

common approach. However, in 25% to 30% of
patients the abdomen cannot be closed without
significant tension secondary to swollen bowel,
excessive tissue edema, or massive
retroperitoneal hematoma (ACS).
J Vasc Surg. 2002; 35: 246-253.
Postoperative complications

 renal failure
 arterial ischemia
 colonic ischemia
 wound infection
 bleeding
 abdominal compartment syndrome.
decompression
 In the abdomen, elevated compartment pressure is
manifested by the following triad:

 Oliguria

 Reduced cardiac output that does not improve

with intravascular fluid replacement

 Hypoxia and Increased airway pressures

Abdominal perfusion pressure (APP)

APP = MAP – IAP

In one retrospective study, the inability to maintain an
APP above 50 mmHg predicted mortality with greater
sensitivity and specificity than either IAP or MAP
alone . Studies suggest that maintaining an APP of 60
mmHg represents an appropriate resuscitation goal.
 Vacuum-assisted temporary abdominal
closure

Bogota Bag
ENDOVASCULAR AORTIC REPAIR
(EVAR)
Currently, open surgical repair is reserved for
those who are anatomically unsuitable for EVAR,
for environments where EVAR is not available, or
when EVAR fails to seal the AAA.

The proportion of RAAAs suitable for EVAR is

variable but has been calculated at between 47%
and 67% based on two recent meta analyses.

J Vasc Surg. 2008; 47: 214-221.

In stable patients, standard EVAR is performed
although an aortouniiliac device followed by
a femorofemoral crossover graft may achieve
more rapid control of intrabdominal hemorrhage.
Exclusion criteria for REVAR include neck length
less than 1 cm, neck diameter greater than 32
mm, angulation greater than 60 degrees, common
iliac diameter greater than 20 mm or less than 6
mm, and inability to preserve at least one internal
iliac artery.

Use of an endovascular approach appears to

reduce 30-day mortality by 10% to 20%.
OPEN VERSUS EVAR FOR RAAA
There is increasing evidence that REVAR is
able to decrease the mortality of RAAA repair
with fewer complications (bleeding, renal,
and respiratory) and shorter hospital stays.

Analysis of mortality rates of REVAR cases

between 2000 and 2003 noted a significant
reduction in the mortality of RAAA patients
treated by EVAR (30 versus 50%)

J Vasc Surg. 2006; 43: 446-451.