Skip to main content
Review

Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections

Published Online:https://doi.org/10.1024/0301-1526/a000760

Abstract. The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.

Literature

  • Rutherford R. Vascular surgery. Philadelphia: Saunders; 2005. First citation in articleGoogle Scholar

  • Assar A & Zarins C. Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J. 2009;85(1003):268–273. First citation in articleCrossref MedlineGoogle Scholar

  • Mehta M, Byrne J, Darling R, Paty P, Roddy S & Kreienberg P et al. Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. J Vasc Surg. 2013;57(2):368–375. First citation in articleCrossref MedlineGoogle Scholar

  • Chaikof E, Brewster D, Dalman R, Makaroun M, Illig K & Sicard G et al. The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4):S2–S49. First citation in articleCrossref MedlineGoogle Scholar

  • Ullery B, Hallett R & Fleischmann D. Epidemiology and contemporary management of abdominal aortic aneurysms. Abdom Radiol. 2018;43(5):1032–1043. First citation in articleCrossref MedlineGoogle Scholar

  • Moneta G. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. Yearbook of Vascular Surgery. 2011;2011:103–105. First citation in articleCrossrefGoogle Scholar

  • Miller F. Oxidative Stress in Human Abdominal Aortic Aneurysms: A Potential Mediator of Aneurysmal Remodeling. Arterioscler Thromb Vasc Biol 2002;22(4):560–565. First citation in articleCrossref MedlineGoogle Scholar

  • Soares Ferreira R, Gomes Oliveira N, Oliveira-Pinto J, van Rijn MJ, Ten Raa S, Verhagen HJ & Bastos Gonçalves F. Review on management and outcomes of ruptured abdominal aortic aneurysm in women. J Cardiovasc Surg (Torino). 2018 Apr;59(2):195–200. First citation in articleMedlineGoogle Scholar

  • Scott R. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet. 2002; 360(9345):1531–1539. First citation in articleCrossref MedlineGoogle Scholar

  • Bhak R, Wininger M, Johnson G, Lederle F, Messina L & Ballard D et al. Factors Associated With Small Abdominal Aortic Aneurysm Expansion Rate. JAMA Surg. 2015;150(1):44. First citation in articleCrossref MedlineGoogle Scholar

  • Sicard G. Human abdominal aortic aneurysms: Immunophenotypic analysis suggesting an immune-mediated response. J Vasc Surg. 1992;15(3):592–593. First citation in articleCrossrefGoogle Scholar

  • Acosta S, Ögren M, Bengtsson H, Bergqvist D, Lindblad B & Zdanowski Z. Increasing incidence of ruptured abdominal aortic aneurysm: A population-based study. J Vasc Surg. 2006;44(2): 237–243. First citation in articleCrossref MedlineGoogle Scholar

  • Raux M, Marzelle J, Kobeiter H, Dhonneur G, Allaire E & Cochennec F et al. Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes. J Vasc Surg. 2015;61(2):304–308. First citation in articleCrossref MedlineGoogle Scholar

  • Nakazawa S, Mohara J, Takahashi T, Koike N & Takeyoshi I. Aortocaval Fistula Associated with Ruptured Abdominal Aortic Aneurysm. Ann Vasc Surg. 2014;28(7):1793.e5–1793.e9. First citation in articleCrossrefGoogle Scholar

  • Zhou J, Xu Q, Shen L, Pan K & Mou Y. Aortoduodenal fistula following aortic reconstruction of a pseudoaneurysm caused by stab wound 12 years ago. J Zhejiang Univ Sci B. 2009;10(5):400–403. First citation in articleCrossref MedlineGoogle Scholar

  • Rengier F, Geisbüsch P, Vosshenrich R, Müller-Eschner M, Karmonik C, Schoenhagen P, … Partovi S. State-of-the-art aortic imaging: part I – fundamentals and perspectives of CT and MRI. Vasa. 2013 Nov;42(6):395–412. First citation in articleLinkGoogle Scholar

  • Rengier F, Geisbüsch P, Schoenhagen P, Müller-Eschner M, Vosshenrich R, Karmonik C, … Partovi S. State-of-the-art aortic imaging: Part II – applications in transcatheter aortic valve replacement and endovascular aortic aneurysm repair. Vasa. 2014 Jan;43(1):6–26. First citation in articleLinkGoogle Scholar

  • Smith F. Emergency Control of Ruptured Abdominal Aortic Aneurysm By Transaxillary Balloon Catheter. Vasc Surg. 1972;6(2): 79–84. First citation in articleCrossref MedlineGoogle Scholar

  • Matsuda H, Tanaka Y, Hino Y, Matsukawa R, Ozaki N & Okada K et al. Transbrachial arterial insertion of aortic occlusion balloon catheter in patients with shock from ruptured abdominal aortic aneurysm. J Vasc Surg. 2003;38(6):1293–1296. First citation in articleCrossref MedlineGoogle Scholar

  • Nakayama H, Toma M, Kobayashi T, Ohno N, Okada T & Ueno G et al. Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series. Ann Thor Cardiovasc Surg. 2018. First citation in articleCrossref MedlineGoogle Scholar

  • Ten Bosch J, Teijink J, Willigendael E & Prins M. Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients. J Vasc Surg. 2010;52(1):13–18. First citation in articleCrossref MedlineGoogle Scholar

  • Karkos C, Menexes G, Patelis N, Kalogirou T, Giagtzidis I & Harkin D. A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 2014;59(3):829–842. First citation in articleCrossref MedlineGoogle Scholar

  • van Beek S, Conijn A, Koelemay M & Balm R. Editor’s Choice – Endovascular Aneurysm Repair Versus Open Repair for Patients with a Ruptured Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis of Short-term Survival. Eur J Vasc Endovasc Surg. 2014;47(6):593–602. First citation in articleCrossref MedlineGoogle Scholar

  • Sarac T, Bannazadeh M & Rowan A. Comparative Predictors of Mortality for Endovascular and Open Repair of Ruptured Infrarenal Abdominal Aortic Aneurysms. J Vasc Surg. 2011;54(6):1847. First citation in articleCrossrefGoogle Scholar

  • Powell J, Thompson S, Thompson M, Grieve R, Nicholson A & Nicholson A et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) Aneurysm Trial-ISRCTN 48334791 IMPROVE trialists. Acta Chir Belg. 2009;109(6):678–680. First citation in articleCrossref MedlineGoogle Scholar

  • Cho J, Kim J, Rhee R, Gupta N, Marone L & Dillavou E et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: Effect of surgeon volume on mortality. J Vasc Surg. 2008;48(1):10–18. First citation in articleCrossref MedlineGoogle Scholar

  • McPhee J, Eslami M, Arous E, Messina L & Schanzer A. Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001–2006): A significant survival benefit over open repair is independently associated with increased institutional volume. J Vasc Surg. 2009;49(4):817–826. First citation in articleCrossref MedlineGoogle Scholar

  • Brinster C, Fairman R, Woo E, Wang G, Carpenter J & Jackson B. Late open conversion and explantation of abdominal aortic stent grafts. J Vasc Surg. 2011;54(1):42–46. First citation in articleCrossref MedlineGoogle Scholar

  • Chang C, Chuter T, Niemann C, Shlipak M, Cohen M & Reilly L et al. Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2009;49(5):1140–1146. First citation in articleCrossref MedlineGoogle Scholar

  • Champagne B, Darling R, Daneshmand M, Kreienberg P, Lee E & Mehta M et al. Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm. J Vasc Surg. 2004; 39(4):792–796. First citation in articleCrossref MedlineGoogle Scholar

  • Moulakakis K, Dalainas I, Mylonas S, Giannakopoulos T, Avgerinos E & Liapis C. Conversion to Open Repair After Endografting for Abdominal Aortic Aneurysm: A Review of Causes, Incidence, Results, and Surgical Techniques of Reconstruction. J Endovasc Ther. 2010;17(6):694–702. First citation in articleCrossref MedlineGoogle Scholar

  • Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ & Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897. First citation in articleCrossref MedlineGoogle Scholar

  • Troisi N. Ruptured Abdominal Aortic Aneurysm: Open Or Endovascular Repair? Angiology: Open Access. 2013;01(01). First citation in articleCrossrefGoogle Scholar

  • Mehta M, Taggert J, Darling R, Chang B, Kreienberg P & Paty P et al. Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: Outcomes of a prospective analysis. J Vasc Surg. 2006;44(1):1–8. First citation in articleCrossref MedlineGoogle Scholar

  • Debakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES & Beall AC Jr. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc. Surg. 1965;49:130–49. First citation in articleGoogle Scholar

  • Daily P, Trueblood H, Stinson E, Wuerflein R & Shumway N. Management of Acute Aortic Dissections. Ann Thorac Surg. 1970; 10(3):237–247. First citation in articleCrossref MedlineGoogle Scholar

  • Grabenwoger M, Alfonso F, Bachet J, Bonser R, Czerny M & Eggebrecht H, et al. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2012;33(13):1558–63. First citation in articleMedlineGoogle Scholar

  • Suzuki T. Clinical Profiles and Outcomes of Acute Type B Aortic Dissection in the Current Era: Lessons From the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108(90101): 312II–317. First citation in articleCrossrefGoogle Scholar

  • Olsson C, Thelin S, Stahle E, Ekbom A & Granath F. Thoracic Aortic Aneurysm and Dissection: Increasing Prevalence and Improved Outcomes Reported in a Nationwide Population-Based Study of More Than 14 000 Cases From 1987 to 2002. Circulation. 2006;114(24):2611–2618. First citation in articleCrossref MedlineGoogle Scholar

  • Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS & Curi MA, et al. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts has been supported by Unrestricted Educational Grants from Cook, Inc and Medtronic, Inc. Ann Thorac Surg. 2008;85(1). First citation in articleGoogle Scholar

  • Nienaber C, Zannetti S, Barbieri B, Kische S, Schareck W & Rehders T. INvestigation of STEnt grafts in patients with type B Aortic Dissection: Design of the INSTEAD trial—a prospective, multicenter, European randomized trial. Am Heart J. 2005;149(4): 592–599. First citation in articleCrossref MedlineGoogle Scholar

  • Hiratzka L, Bakris G, Beckman J, Bersin R, Carr V & Casey D et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Medicine. Circulation. 2010;121 (13):e266–e369. First citation in articleMedlineGoogle Scholar

  • MacKenzie K, LeGuillan M, Steinmetz O & Montreuil B. Management Trends and Early Mortality Rates for Acute Type B Aortic Dissection: A 10-Year Single-Institution Experience. Ann Vasc Surg. 2004;18(2):158–166. First citation in articleCrossref MedlineGoogle Scholar

  • Tsai T, Trimarchi S & Nienaber C. Acute Aortic Dissection: Perspectives from the International Registry of Acute Aortic Dissection (IRAD). Eur J Vasc Endovasc Surg. 2009;37(2):149–159. First citation in articleCrossref MedlineGoogle Scholar

  • Vilacosta I, Aragoncillo P, Canadas V, Roman J, Ferreiros J & Rodriguez E. Acute aortic syndrome: a new look at an old conundrum. Postgrad Med J. 2010;86(1011):52–61. First citation in articleCrossref MedlineGoogle Scholar

  • Goljan E. Pathology. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2014. First citation in articleGoogle Scholar

  • Nienaber C & Powell J. Management of acute aortic syndromes. Eur Heart J. 2011;33(1):26–35. First citation in articleCrossref MedlineGoogle Scholar

  • Klompas M. Does This Patient Have an Acute Thoracic Aortic Dissection? JAMA. 2002 Jan;287(17):2262. First citation in articleCrossref MedlineGoogle Scholar

  • Kodolitsch YV, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T & Brekenfeld C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73–7. First citation in articleCrossref MedlineGoogle Scholar

  • Kodolitsch YV, Schwartz AG & Nienaber CA. Clinical Prediction of Acute Aortic Dissection. Arch Intern Med. 2000;160(19):2977. First citation in articleCrossref MedlineGoogle Scholar

  • Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R & Coppi G, et al. Editors Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg. 2017;53(1):4–52. First citation in articleCrossref MedlineGoogle Scholar

  • Fukui T. Management of acute aortic dissection and thoracic aortic rupture. J Intensive Care 2018;6(1). First citation in articleCrossref MedlineGoogle Scholar

  • Evangelista A, Flachskampf FA, Erbel R, Antonini-Canterin F, Vlachopoulos C & Rocchi G, et al. Echocardiography in aortic diseases: EAE recommendations for clinical practice. Eur J Echocardiogr. 2010J;11(8):645–58. First citation in articleCrossref MedlineGoogle Scholar

  • François CJ, Markl M, Schiebler ML, Niespodzany E, Landgraf BR & Schlensak C, et al. Four-dimensional, flow-sensitive magnetic resonance imaging of blood flow patterns in thoracic aortic dissections. J Thorac Cardiovasc Surg. 2013;145(5):1359–66. First citation in articleCrossref MedlineGoogle Scholar

  • Mehta RH. Predicting Death in Patients With Acute Type A Aortic Dissection. Circulation. 2002;105(2):200–6. First citation in articleCrossref MedlineGoogle Scholar

  • Trimarchi S. Role and Results of Surgery in Acute Type B Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006Apr;114(1_suppl). First citation in articleCrossrefGoogle Scholar

  • Tsai TT, Fattori R, Trimarchi S, Isselbacher E, Myrmel T & Evangelista A, et al. Long-Term Survival in Patients Presenting With Type B Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. Circulation. 2006Jun; 114(21):2226–31. First citation in articleCrossref MedlineGoogle Scholar

  • Swee W & Dake MD. Endovascular Management of Thoracic Dissections. Circulation. 2008;117(11):1460–73. First citation in articleCrossref MedlineGoogle Scholar

  • Sakakura K, Kubo N, Ako J, Fujiwara N, Funayama H & Ikeda N, et al. Determinants of Long-Term Mortality in Patients With Type B Acute Aortic Dissection. Am J Hypertens. 2009Jan;22(4):371–7. First citation in articleCrossref MedlineGoogle Scholar

  • Genoni M, Paul M, Jenni R, Graves K, Seifert B & Turina M. Chronic ß-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection. Eur J Cardiothorac Surg. 2001;19(5):606–10. First citation in articleCrossref MedlineGoogle Scholar

  • Lacro RV, Dietz HC, Sleeper LA, Yetman AT, Bradley TJ & Colan SD, et al. Atenolol versus Losartan in Children and Young Adults with Marfans Syndrome. NEJM. 2014;371(22):2061–71. First citation in articleCrossref MedlineGoogle Scholar

  • Neal B & Macmahon S. An Overview of 37 Randomised Trials of Blood Pressure Lowering Agents Among 270 000 Individuals. Clin Exp Hypertens. 1999;21(5–6):517–29. First citation in articleCrossref MedlineGoogle Scholar

  • Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002;74(5). First citation in articleCrossrefGoogle Scholar

  • Estrera AL, Miller CC, Goodrick J, Porat EE, Achouh PE & Dhareshwar J, et al. Update on Outcomes of Acute Type B Aortic Dissection. Ann Thorac Surg. 2007;83(2). First citation in articleCrossrefGoogle Scholar

  • Trimarchi S, Eagle K & Nienaber C. Importance of Refractory Pain and Hypertension in Acute Type B Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection (IRAD). J Vasc Surg. 2011;53(3):878. First citation in articleCrossrefGoogle Scholar

  • Umaña JP, Miller D & Mitchell R. What is the best treatment for patients with acute type B aortic dissections – medical, surgical, or endovascular stent-grafting? Ann Thorac Surg. 2002;74(5). First citation in articleCrossref MedlineGoogle Scholar

  • Zeeshan A, Woo EY, Bavaria JE, Fairman RM, Desai ND & Pochettino A, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: Superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010;140(6). First citation in articleCrossref MedlineGoogle Scholar

  • Fattori R, Montgomery D, Lovato L, Kische S, Eusanio MD & Ince H, et al. Survival After Endovascular Therapy in Patients With Type B Aortic Dissection. JACC Cardiovasc Interv. 2013;6(8):876–82. First citation in articleCrossref MedlineGoogle Scholar

  • Collins J. Differences in Clinical Presentation, Management, and Outcomes of Acute Type A Aortic Dissection in Patients With and Without Previous Cardiac Surgery. Circulation. 2004; 110(11_suppl_1):II-237–II-242. First citation in articleCrossrefGoogle Scholar

  • Eggebrecht H, Naber CK, Bruch C, Kröger K, Birgelen CV & Schmermund A, et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. JACC. 2004;44(4):804–9. First citation in articleCrossref MedlineGoogle Scholar

  • Schlösser FJ, Verhagen HJ, Lin PH, Verhoeven EL, Herwaarden JAV & Moll FL, et al. TEVAR following prior abdominal aortic aneurysm surgery: Increased risk of neurological deficit. J Vasc Surg. 2009;49(2):308–14. First citation in articleCrossref MedlineGoogle Scholar

  • Matsumura JS, Lee WA, Mitchell RS, Farber MA, Murad MH & Lumsden AB, et al. The Society for Vascular Surgery Practice Guidelines: Management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 2009;50(5): 1155–8. First citation in articleCrossref MedlineGoogle Scholar

  • Eggebrecht H, Thompson M, Rousseau H, Czerny M, Lonn L & Mehta RH, et al. Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement: Insight From the European Registry on Endovascular Aortic Repair Complications. Circulation. 2009;120. First citation in articleMedlineGoogle Scholar

  • Bonderman D, Gharehbaghi-Schnell E, Wollenek G, Maurer G, Baumgartner H & Lang I. Mechanisms Underlying Aortic Dilatation in Congenital Aortic Valve Malformation. Circulation. 1999;99(16):2138–2143. First citation in articleCrossref MedlineGoogle Scholar

  • Eagle KA, Isselbacher EM & Desanctis RW. Cocaine-Related Aortic Dissection in Perspective. Circulation. 2002;105(13):1529–30. First citation in articleCrossref MedlineGoogle Scholar