Ruptured abdominal aortic aneurysm: treatment strategy and choice of procedure

The ruptured infrarenal abdominal aortic aneurysm, despite technical advances in operating procedures, anesthesiology and intensive care medicine, continues to represent a life-threatening emergency with very bad prognosis. Nine out of ten patients pass away before reaching the hospital, mortality rates for patients treated operatively vary between 35 and 70%. The negative post-operative results are mainly due to the comorbidity of the mostly older patients with the deterioration of organ function and simultaneous hemorrhagic shock. For the past 50 years, the ruptured aortic aneurysm has been operated transperitoneally via conventional vascular prosthetic replacement. For the past ten years, there has also been the option of treating aortic emergencies endovascularly by means of a stent prosthesis (eEVAR; emergency endovascular aortic repair). By implanting an endograft system, the operative trauma of a laparotomy is dispensed with, and aortic clamping, with the accompanying pathophysiologic stresses is also avoided. Another advantage is that the operation can be performed under local anesthesia. When selecting an operative procedure, in addition to morphologic conditions, a suitable infrastructural environment needs to be assured. There are no clear answers in the final analysis of the relative value of eEVAR. It is both necessary and ethically justifiable that prospective randomized studies be performed to establish a preference.