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General Considerations of Ruptured Abdominal Aortic Aneurysm: Ruptured Abdominal Aortic Aneurysm

Although development of surgical technique and critical care, ruptured abdominal aortic aneurysm still carries a high mortality. In order to obtain good results, various efforts have been attempted. This paper reviews initial management of ruptured abdominal aortic aneurysm and discuss the key point open surgical repair and endovascular aneurysm repair.


INTRODUCTION
Due to developments in surgical technique and critical care, the mortality rate of elective abdominal aortic aneurysm repair has been greatly improved. However, Cooley and DeBakey's early presentation of surgical treatments for ruptured abdominal aortic aneurysms (rAAA) noted a 50% survival rate [1], which has proven difficult to improve over six decades of subsequent effort [2][3][4].
Nevertheless, OSR still plays an important role in the treatment of rAAA due to the anatomical and institutional limitations of EVAR. In this article, we review strategies for the initial management of rAAA in order to reduce perioperative mortality and morbidity and discuss key features of OSR and EVAR.

INITIAL MANAGEMENT
Preoperative hemodynamic stability is directly associated with the patient's mortality [9][10][11], and preoperative shock is the most serious risk factor affecting survival after rAAA.
For this reason, it is important to stabilize the patient's blood pressure. However, aggressive fluid resuscitation before achieving control of the proximal aorta can lead to further hemorrhaging, which may result in an increased risk of mortality [11]. Thus, the primary goal in the initial management of patients with rAAA is achieving hemodynamic stability to allow perfusion of the vital organs. This is the concept underlying permissive hypotension [12]. This usually involves maintaining a systolic blood pressure of 70 to 80 mmHg, and avoiding aggressive resuscitation to pressures higher than 100 mmHg [13]. Dick et al. [14] report that aggressive volume resuscitation of patients with rAAA before proximal aortic control resulted in an increased perioperative risk of death in-

OPEN SURGICAL MANAGEMENT
Coordination between the surgeon, anesthesiologist, and scrub nurse is important for the successful operation. There are two ways to approach the abdominal aorta: the transperitoneal approach through a median laparotomy and the retroperitoneal approach. The transperitoneal approach is generally preferred because it enables the surgeon to examine the intra-abdominal organs and perform quick supraceliac clamping [17][18][19]. On the other hand, some investigators advocate the retroperitoneal approach, as it is associated with less intraoperative hypotension and lower mortality than the transperitoneal approach [20,21]. The most important factor in choosing the incision path is the familiarity of the surgeon with each method.
The most important step in surgery on a patient with rAAA is the rapid, safe, and effective control of the proximal aorta with a consequent reduction of blood loss. After aortic clamping takes place, the anesthesia team should replace blood loss more aggressively. Several options exist for establishing control of the aorta. Supraceliac control has the advantage of allowing the quick and safe control of the aorta in a bloodless field. However, it has the disadvantage of inflicting an ischemic injury on a visceral organ, which can lead to further visceral injuries through hemorrhagic shock, which in turn may ultimately contribute to the development of multisystem organ failure [18,22]. In addition, supraceliac control can increase the cardiac afterload and promote myocardial ischemia [23]. Another method for aortic control is balloon occlusion. Proximal control of the aorta can be carried out by placing a balloon in the proximal aorta without supraceliac exposure. An occlusion balloon can be inserted directly through the aorta or with fluoroscopic guidance through femoral or brachial artery [15].
Although it is controversial, heparin should be administered as soon as aortic clamp control is established [24]. Due to the risk of coagulation disorders, dissections should be minimized to reduce injury to blood vessels and other structures.
The patient should be kept warm because hypothermia can lead to surgical bleeding and adverse cardiac events [15]. Use of red blood cell saver during surgery has been proven to reduce blood-product use in rAAA surgery [25].

ENDOVASCULAR MANAGEMENT
The first successful endovascular repair of a rAAA was performed in 1994 by Marin et al. [26]. Since EVAR has some theoretical advantages over OSR, it has been increasingly used to treat rAAA. It is less invasive, avoids damage to periaortic and abdominal structures, reduces bleeding from surgical dissection, minimizes hypothermia, and lessens the requirement for deep anesthesia [27]. Because of these potential advantages combined with reports of lower procedural mortality, EVAR has been regarded as superior to OSR for the treatment of rAAA [28][29][30][31][32].
When performing EVAR on a patient with rAAA, the sur- cally unstable patients or when it is difficult to access the contralateral iliac artery due to stenosis, occlusion, or tortuosity [34].
ACS is the major cause of morbidity and mortality after EVAR performed to treat rAAA [24]. Several factors contribute to the occurrence of ACS after EVAR in patients with rAAA. Retroperitoneal hematomas are lesions that occupy a significant amount of space in the abdomen and are a significant factor contributing to intra-abdominal hypertension.
Persistent bleeding from the lumbar and inferior mesenteric arteries into the ruptured aneurysm sac in the situation of severe coagulopathy might also contribute to the development of ACS [35]. Moreover, the state of shock involved in rAAA is associated with alterations in microvascular permeability that can lead to visceral and soft tissue edema. Monitoring of bladder pressure is helpful for the early detection of ACS [29,32]. Laparotomy and open abdomen treatment are needed to relieve the hypotension, high pulmonary compliance, and oliguria that occur in serious cases of ACS [24]. Although these trials had some limitations due to the relatively small number of patients who were recruited, no significant differences were found between EVAR and OSR regarding either the mortality rate or the complication rate.

OPEN SURGICAL REPAIR COMPARED TO ENDOVASCULAR ANEURYSM REPAIR
Van Beek et al. [39] performed a meta-analysis of 3,769 studies assessing short-term survival rates in patients with rAAA. They concluded that EVAR and OSR have comparable outcomes in patients with rAAA, which supports using EVAR in suitable patients while reserving OSR as an alternative strategy.

CONCLUSION
Most patients with rAAA die before they can be operated upon [40]. Furthermore, surgery for rAAA has a high mortality rate. After decades of marginal improvements in OSR survival rates, a paradigm shift has occurred. Endovascular techniques, advances in perioperative management, and centralization of services have improved outcomes, with substantial reductions in mortality in some regions [41][42][43].
One study has reported a mean of 8.5 quality-adjusted life years for hospital survivors of rAAA surgery [38]. No difference was observed in the quality of life of rAAA patients who had major postoperative complications compared to those who did not. Therefore, patients who survive rAAA repair have an acceptable quality of life, which suggests that a continued aggressive approach to repair is indicated [44].

CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.