Acute Aortic Disease.. - Index of

Treatment of Ruptured Aortic Aneurysms 211
abdominal pain do not suffer from ruptured AAA. In these situations CT scans can
be of utmost help in avoiding a negative laparotomy. The sensitivity and specificity
of CT scans for ruptured AAA have been estimated to be 79% and 78%, respectively
(51). Despite this there appears to be clinical advantage in judgmental use
of CT scanners for diagnosis. Kvilekval et al. (52) studied 65 hemodynamically
stable patients with AAA and abdominal and back pain. There were no deaths
related to the delay caused by obtaining the CT scan. The study provided useful
anatomic information in 28% of patients, and in 70% of patients, emergency
surgery was avoided.
Thus we recommend CT scans of the chest and abdomen with intravenous
contrast for all hemodynamically stable patients in whom there is a suspicion for
symptomatic or ruptured thoracic aortic aneurysm.
The CT scan should be obtained with and without intravenous contrast.
The noncontrast scans allow for detection of fresh hematomas, and the contrast
images permit accurate identification of the anatomy of the aneurysm. CT findings
suggestive of ruptured abdominal aortic aneurysm include obscuration of the
retroperitoneum and displacement of the aneurysm by an irregular high-density
collection. The kidneys may also be displaced anteriorly by a perinephric
fluid collection. Other signs include enlargement of the psoas muscle contour and
a crescent shaped area of high attenuation within the wall or mural thrombus of
the aneurysm (53–55). Rapid opacification of the inferior vena cava suggests an
aortocaval fistula.
MANAGEMENT OF RUPTURED AORTIC ANEURYSMS
General Considerations
While hemodynamic stability affords the opportunity to obtain imaging, the
converse requires expeditious transfer to the OR for emergency surgery. Successful
management of the unstable patient with ruptured aortic aneurysm requires a high
index of suspicion, an experienced surgical team, and a clear plan and pathway for
treatment.
Patients with ruptured aortic aneurysms should not be denied therapy on the
basis of any specific set of preoperative factors. According to Halpern et al. (56)
there is no correlation between preexisting medical comorbidities in ruptured
aortic abdominal aneurysm patients and the immediate perioperative outcome.
However, that series did find that hemoglobin level less than 10 mg/mL, loss of
consciousness, and creatinine >1.5 mg/mL were predictive of death.
Ruptured Thoracic Aortic Aneurysm and Thoracoabdominal
Aortic Aneurysm—Open Repair
Distal Arch/Proximal Descending Aortic Rupture
Efficient transfer of the patient to the operating suite is of paramount importance.
While there is no absolute requirement for selective ventilation, this may be