Diagnosis and management symptomatic (nonruptured, ruptured) abdominal aortic aneurysm

AAA: abdominal aortic aneurysm; BP: blood pressure; CT: computed tomography; MRI: magnetic resonance imaging.
* Permissive hypotension targets systolic BP 80 to 100 mmHg.
¶ Intravenous contrast is not absolutely required to diagnose rupture but is highly desired if endovascular repair is an option.
Δ Ultrasound can be performed at the bedside or in the operating room. In a patient with an appropriate history and clinical findings, ultrasound may not be necessary.
◊ In the absence of overt rupture, no radiologic signs have been proven to predict AAA rupture for certain, but signs associated with impending AAA rupture have included: crescent sign, layering hematoma, aortic blebs, aortic draping over a vertebral body, irregular aortic wall, breaks in calcification of the aortic wall, and localized areas of higher attenuation within mural thrombus. In combination with an AAA of >5 cm, these signs may indicate a rapidly changing aneurysm and urgency for repair.
§ The aneurysm is managed as with other asymptomatic AAA.
¥ For patients with symptomatic (ruptured, nonruptured) AAA, an endovascular first approach is generally preferred if anatomically suitable and institutional resources, endovascular devices, and expertise are available. Otherwise, open surgical repair can be performed.
‡ Initial wire access and aortic occlusion balloon placement can precede repair as a temporizing measure to limit bleeding.
† Obtain CT angiography, if contrast study not previously performed.