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 and groin. On examination, he is hypotensive (BP 85/55 mmHg), tachycardic (HR 118/min), and in severe distress. His abdomen is rigid with a pulsatile mass palpable in the epigastrium. Femoral pulses are diminished bilaterally. A stat non-contrast CT angiography of the chest and abdomen shows a 7 cm infrarenal aortic aneurysm with active extravasation of contrast into the retroperitoneum. What is the most appropriate immediate management?

Explanation

## Diagnosis: Ruptured Abdominal Aortic Aneurysm (rAAA) ### Clinical Presentation **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 active extravasation. **High-Yield:** Active extravasation on CT indicates ongoing hemorrhage into the retroperitoneum — this is a surgical emergency with mortality >50% if not rapidly repaired. ### Management Algorithm ```mermaid flowchart TD A[Ruptured AAA confirmed]:::outcome --> B{Hemodynamically stable?}:::decision B -->|No - Hypotensive| C[Immediate OR for open repair]:::urgent B -->|Yes - Stable| D[Consider EVAR if anatomy suitable]:::action C --> E[Aortic cross-clamp + repair]:::action D --> F[Endovascular repair]:::action E --> G[Mortality ~50% even with surgery]:::outcome F --> H[Lower mortality if stable]:::outcome ``` ### Why Immediate Open Repair? 1. **Hemodynamic instability** (BP 85/55) — patient cannot tolerate the time required for endovascular setup, imaging, and catheterization. 2. **Active extravasation** — ongoing blood loss into retroperitoneum; every minute of delay increases mortality. 3. **Permissive hypotension principle does NOT apply here** — the patient is already severely hypotensive; the goal is rapid aortic control and repair, not further delay. 4. **Open repair is faster** in unstable patients — direct aortic cross-clamp and repair takes ~30–45 minutes in experienced hands. **Clinical Pearl:** In rAAA, the phrase "time is tissue" applies to the aorta, not the brain. Rapid surgical control of hemorrhage is the only life-saving intervention. ### Mortality Context - **Ruptured AAA overall mortality:** 80–90% (includes pre-hospital deaths). - **Mortality if surgery performed:** ~50% (this patient's risk). - **Mortality if no surgery:** ~100%. **High-Yield:** Endovascular repair (EVAR) is preferred in stable patients with suitable anatomy, but this patient's hemodynamic collapse mandates open repair without delay. [cite:Sabiston Textbook of Surgery 21e Ch 63]