A 68-year-old man with a history of hypertension and smoking presents to the emergency department with sudden-onset severe back pain radiating to the left flank. He is diaphoretic and appears in distress. Blood pressure is 165/95 mmHg in the right arm and 140/85 mmHg in the left arm. Pulse is 110/min. On examination, a pulsatile abdominal mass is palpable. A stat CT angiography of the chest and abdomen with IV contrast shows a large infrarenal aortic aneurysm with active extravasation of contrast into the retroperitoneum. What is the most appropriate immediate management?

Explanation

## Ruptured Abdominal Aortic Aneurysm (rAAA): Acute Management ### Clinical Recognition **Key Point:** The classic triad of rAAA is sudden severe back/flank pain, hypotension, and a pulsatile abdominal mass. This patient has all three, plus imaging confirmation of rupture with active extravasation. ### Permissive Hypotension Strategy **High-Yield:** In ruptured AAA, the goal is NOT to restore normal blood pressure immediately. Aggressive fluid resuscitation and normalization of BP increase bleeding and mortality. **Clinical Pearl:** Permissive hypotension (target systolic 70–90 mmHg) maintains organ perfusion while minimizing further bleeding. This is the standard of care in modern trauma and vascular surgery. ### Why This Approach? 1. Reduces shear stress on the aortic wall 2. Decreases further extravasation 3. Avoids "popping the clot" — the retroperitoneal hematoma is tamponading the bleeding 4. Improves survival when combined with rapid surgical intervention ### Surgical Timing **Key Point:** Rapid transfer to the operating room is critical. Time from diagnosis to incision should be <60 minutes ("golden hour" concept). ### Intraoperative Approach - Open surgical repair (aortic cross-clamping, graft interposition) remains the gold standard for rAAA - Endovascular repair (EVAR) may be considered in select hemodynamically stable patients with favorable anatomy, but this patient is unstable - Permissive hypotension is maintained until aortic control is achieved ### Summary Table: rAAA Management Principles | Principle | Rationale | | --- | --- | | Permissive hypotension (SBP 70–90) | Minimize bleeding, prevent clot disruption | | Rapid OR transfer | Reduce time to aortic control | | Open repair (first-line) | Fastest definitive control in unstable patient | | Avoid aggressive fluid resuscitation | Increases bleeding and mortality | | Avoid vasodilators alone | Worsens hypotension without aortic control | [cite:Robbins 10e Ch 10]