Ruptured Aortic Aneurysm

What to do right away

1. Call 911 or your local emergency number. Say you suspect a ruptured aneurysm if the person has a known aneurysm.
2. Keep the person lying down and as still and calm as possible.
3. Do not give food or drink, as emergency surgery is likely.
4. If they become unresponsive and are not breathing normally, start CPR.

What happens when an aneurysm ruptures

An aneurysm is a permanent bulge where the aortic wall has weakened, most often in the abdomen below the kidney arteries. A normal abdominal aorta is about 2 cm (under 1 in) wide; an aneurysm is 3 cm or more. As it widens, wall tension rises and the risk of rupture climbs steeply.

When it bursts:

• Most often, blood leaks behind the abdominal cavity (retroperitoneal rupture). Surrounding tissues briefly contain the bleed, which may buy minutes to hours.
• Less often, it bursts into the free abdominal cavity, causing rapid, usually fatal blood loss.
• Rarely, it ruptures into the bowel or a large vein, causing gut bleeding or heart failure.

Thoracic aneurysms in the chest can also rupture, causing sudden chest or upper back pain and collapse. They are often linked to aortic dissection.

Symptoms of a ruptured aortic aneurysm

• Sudden, severe, persistent pain in the belly, lower back or side, often described as tearing or ripping
• Pain spreading to the groin, buttocks or legs
• Dizziness, fainting or collapse
• Sweating, pale clammy skin, nausea or vomiting
• Fast heart rate and low blood pressure (signs of hemorrhagic shock)
• A pulsing lump in the belly in thinner people

The classic triad is pain, low blood pressure and a pulsating abdominal mass, but all three are present in only about half of cases.

Commonly mistaken for

Ruptured aneurysms are often first misdiagnosed. The most frequent mix-up is kidney stones, because of flank pain and blood in the urine. Others are diverticulitis, pancreatitis, heart attack and back strain. A man over 60 with "renal colic" for the first time should be considered for an aneurysm.

Risk factors for rupture

• Aneurysm size: risk is low below 5.5 cm and rises sharply above it. Aneurysms over 7 cm have a high yearly rupture risk.
• Rapid growth: more than 1 cm a year
• Smoking: the strongest modifiable risk factor for both forming and rupturing
• High blood pressure
• Female sex: women's aneurysms rupture at smaller sizes, so repair is often offered at 5.0 cm
• Family history, older age and atherosclerosis
• Connective tissue disorders such as Marfan syndrome, mostly for thoracic aneurysms

Diagnosis in the emergency room

If the person is unstable and has a known aneurysm, they may go straight to the operating room. Otherwise:

• Bedside ultrasound confirms an aneurysm in minutes.
• CT angiography shows the rupture and the aneurysm's shape, which determines whether a stent graft can be used.
• Blood tests and urgent cross-match for transfusion.

Emergency treatment

• Permissive hypotension: doctors keep blood pressure lower than normal but enough to keep the person conscious, to avoid dislodging the clot that is slowing the bleed.
• Blood transfusion with blood products in balanced ratios.
• Endovascular aneurysm repair (EVAR): a covered stent graft is passed through the groin arteries and placed inside the aneurysm, sealing the leak from within. It is preferred when the anatomy is suitable, and is associated with lower early death rates, especially in women.
• Open repair: the abdomen is opened, the aorta is clamped and the aneurysm is replaced with a fabric tube graft.

Survival and recovery

About 80% of people with a ruptured abdominal aortic aneurysm die, many before reaching the hospital. For those who undergo emergency repair, survival is roughly 50% to 70%, depending on age, health, how unstable they were and the repair method.

Recovery often involves intensive care, and complications can include kidney failure, bowel ischemia, breathing problems, heart attack and abdominal compartment syndrome. Survivors need lifelong scans of the graft, especially after EVAR.

Prevention: screening and planned repair

• Screening: a one-time ultrasound for men aged 65 to 75 who have ever smoked is recommended in the US. The UK screens all men in their 65th year. Screening reduces deaths from aneurysm rupture by about 40% to 50%.
• Surveillance: small aneurysms (3.0 to 5.4 cm) are checked with ultrasound every 1 to 3 years, or more often as they grow.
• Planned repair: usually offered at 5.5 cm in men and 5.0 cm in women, or with rapid growth or symptoms. Planned repair carries a much lower risk, about 1% to 5%, than emergency repair.
• Lifestyle: stop smoking, control blood pressure, and take statins and other heart medicines as advised.

For more on monitoring and planned repair, see abdominal aortic aneurysm and aortic aneurysm.

Frequently asked questions

What are the first signs of a ruptured aortic aneurysm?

Sudden, severe and constant pain in the belly, lower back or side, often described as tearing, followed quickly by dizziness, sweating, a fast pulse and fainting. Anyone with these symptoms, especially over 60 or with a known aneurysm, needs emergency care immediately.

What is the survival rate of a ruptured AAA?

Around 1 in 5 people survive a ruptured abdominal aortic aneurysm, because many die before reaching the hospital. Among those who reach emergency surgery, roughly half to two-thirds survive. Planned repair before rupture is far safer, which is why screening matters.

Can you survive a ruptured aortic aneurysm?

Yes, if the bleeding is contained long enough to reach a hospital that can perform emergency EVAR or open surgery. Fast recognition, calling an ambulance immediately and quick transfer to a vascular surgery center give the best chance.

Can an aortic aneurysm rupture without warning?

Often, yes. Most aneurysms cause no symptoms before they rupture, which is why screening is offered to people at higher risk. Some people notice belly or back pain, or a pulsing sensation, before rupture, which should be checked urgently.

What size aortic aneurysm is likely to rupture?

Rupture risk rises sharply above about 5.5 cm in men and 5.0 cm in women, which is when planned repair is usually offered. Aneurysms that grow more than 1 cm a year or cause pain also need prompt repair, whatever their size.