A 68-year-old man with a 40-year history of smoking and uncontrolled hypertension (BP 160/95 mmHg) presents to the emergency department with sudden onset of severe, tearing back pain radiating to the left flank. He is diaphoretic and anxious. On examination, blood pressure is 95/60 mmHg, heart rate 118/min, and there is a pulsatile abdominal mass. Femoral pulses are diminished bilaterally. A stat CT angiography of the chest and abdomen with IV contrast shows a large descending thoracic aortic aneurysm with active extravasation of contrast into the left pleural space and retroperitoneum. What is the most appropriate immediate management?

Explanation

## Acute Aortic Rupture: Hemodynamic Management Strategy ### Clinical Scenario Recognition This patient presents with the classic triad of acute aortic rupture: - Sudden, severe tearing back/flank pain - Hypotension (95/60) with tachycardia - Imaging evidence of rupture with active extravasation **Key Point:** Acute aortic rupture is a surgical emergency with mortality >1% per hour if untreated. However, the hemodynamic approach differs fundamentally from other shock states. ### The Paradox of Hypotension in Aortic Rupture **High-Yield:** In acute aortic rupture, hypotension is NOT a sign to aggressively fluid-resuscitate. Aggressive fluid administration increases aortic wall stress, shear force (dP/dt), and risk of further rupture and exsanguination before the patient reaches the OR. ### Controlled Hypotension Strategy | Parameter | Target | Rationale | |-----------|--------|----------| | Systolic BP | 100–120 mmHg | Reduces aortic shear stress; minimizes rupture extension | | Heart Rate | <60 bpm | Decreases dP/dt (rate of pressure change); reduces wall tension | | Agent | IV beta-blocker first (esmolol, labetalol) | Reduces contractility AND HR; vasodilators alone cause reflex tachycardia | | Sequence | Beta-blocker THEN vasodilator (nitroprusside, nicardipine) | Never give vasodilator alone—reflex tachycardia worsens shear | **Clinical Pearl:** This is "permissive hypotension" — a counterintuitive but evidence-based approach that reduces mortality in acute aortic pathology by preventing further dissection or rupture during transport and surgical preparation. ### Why This Patient Needs Urgent Repair - Active extravasation on CT = contained rupture with ongoing bleeding - Retroperitoneal and pleural involvement = massive hemorrhage risk - Hemodynamic instability despite hypotensive management = imminent exsanguination - Descending thoracic location = amenable to both open surgical repair and endovascular stent-graft (TEVAR) **Key Point:** The goal is to stabilize the patient hemodynamically while expediting transfer to the OR or hybrid suite. Do NOT delay for further workup once rupture is confirmed. ### Endovascular vs. Open Repair - **TEVAR (Thoracic Endovascular Aortic Repair):** Increasingly first-line for descending thoracic ruptures; faster, less physiologic stress - **Open surgical repair:** Reserved for anatomy unsuitable for TEVAR or when TEVAR unavailable [cite:Harrison 21e Ch 297]