An abdominal aortic aneurysm rupture (rAAA) is life-threatening. Its mortality has consistently been reported to be 100% without either open or endovascular surgical intervention [1]. Chronic contained rupture of an abdominal aortic aneurysm (AAA) is a well-known subtype that is assumed to result from an overlooked “contained” leak in the retroperitoneal space. These occur after retroperitoneal hemorrhage caused by the surrounding structures that form a hematoma [2]. Depending on the site and size of the hematoma, the chronic presentation can vary from more typical symptoms such as back or flank pain [3] to less characteristic symptoms such as lower limb neuropathy [2], obstructive jaundice [4], or vertebral erosion [5]. Most patients were hemodynamically stable [3]. In fact, most of them are suitable for emergency or urgent surgery [3], making them a completely different group from the case we present here.

We identified only three cases of rAAA where patients survived for more than 30 days in the literature. The earliest reference to an rAAA that “spontaneously healed” was reported by Christenson et al. [6] in 1984, where the patient survived for 5 months. We identified another patient from a case series of 12 acute ruptures; all patients died within 48 hours, except for one who presented with a rupture that was treated conservatively, ultimately dying after 15 months due to repeat rAAA [7]. More recently, Tham et al. [8] reported another case where the patient survived for 13 months after conservative treatment of a confirmed rAAA. Interestingly, the patient declined invasive intervention. Although the patient was 87 years old, he had no significant comorbidities. He received a single unit of transfusion and was supported by a permissive hypotension approach.

There has been a recent decrease in the incidence and mortality of rAAAs [9]. This is attributed to various factors, including improvements in risk factor modification, centralization of vascular services, and advances in endovascular techniques, with an increasing use of endovascular aneurysm repair (EVAR) in both elective [10] and emergency settings [11]. Patients with a higher degree of frailty now have another surgical option; thus, fewer patients are managed nonoperatively.

While rAAA mortality has decreased, the mortality rate still remains extremely high. The total mortality for all rAAAs has been estimated to be between 78%-83% [12]; in-hospital mortality is approximately 65.90%, and postoperative mortality is 41.77% (open repair, 42.72%; EVAR, 31.58%) [13].

Here, we report a case of survival after conservative management of a confirmed rAAA. Institutional Review Board approval was waived due to the retrospective case report.

An 86-year-old female presented to her local hospital with a two-day history of lower abdominal cramps, pain, vomiting, and general discomfort. Her vital signs on admission were as follows: pulse, 78 beats per minute; blood pressure, 88/66 mmHg (66 mmHg in the ambulance); and Glasgow Coma Scale score, 15. Upon examination, the abdomen was soft and non-peritonitic. Blood tests revealed elevated levels of inflammatory markers and troponins, with a normal electrocardiogram. She was admitted to the acute frailty unit, and a do-not-resuscitate (DNR) form was implemented. Computed tomography (CT) of the abdomen and pelvis confirmed the diagnosis of rAAA (Fig. 1).

Figure 1. An initial computed tomography scan showed a ruptured abdominal aortic aneurysm.

The patient was known to the local vascular services and was not considered a candidate for surgical repair because of multiple comorbidities, including chronic obstructive pulmonary disease (COPD) with increasing exertional dyspnea, thyroid cancer, diet-controlled diabetes mellitus, osteoporosis, angina, and hypertension. She had a limited exercise tolerance of less than 20 yards. Her aneurysm was juxtarenal (<5 mm neck) and unsuitable for endovascular stenting due to hostile anatomy (short aortic neck with significant angulation). Therefore, she was treated palliatively, which included the cessation of vital sign monitoring. She also had a DNR order in place. She did not receive a blood transfusion and was discharged home with anticipatory medications (including paracetamol, oxycodone, midazolam, glycopyrronium, cyclizine, and fentanyl) and community palliative care follow-up. Although the patient was discharged from the hospital for end-of-life care, she survived from the acute event and regained her normal baseline function at home without further clinical input. Due to this unexpected outcome, the patient was referred back to the vascular team for a reassessment of her overall condition with a repeat CT scan.

The repeat scan (performed 2 months after the initial imaging) showed complete resolution of the previous periaortic hematoma and a 6.5 cm AAA sac reverting to its original morphology with a persistent pointed bulge towards the intraperitoneal direction (Fig. 2).

Figure 2. A computed tomography scan 2 months after initial imaging showed a complete resolution of the rupture.

The patient was examined at a vascular outpatient clinic. She denied any angina or claudication symptoms but reported a limited exercise tolerance of 10-20 yards owing to shortness of breath and severe COPD. Clinically, the patient had an easily palpable, non-tender AAA with bilateral femoral pulses. The case was discussed again in the vascular multidisciplinary team, and in view of her unchanged AAA configuration, multiple comorbidities, poor exercise tolerance, and frailty, the decision was to continue conservative treatment. The patient was still not suitable for any invasive intervention, including EVAR, even in the event of re-rupture. Unfortunately, the patient died 5 months after the rupture event, but the cause of death was not confirmed.

Prior to this case, we were unaware of rAAA survival after conservative treatment, and the literature review suggests that this is the fourth case to report survival after nonsurgical management of rAAA.

All available literature suggests that nonoperative treatment of rAAA results in 100% mortality. Although the number of patients treated conservatively is decreasing [12], a significant proportion are managed nonoperatively [13]. Typically, this consists of an older age group with extensive comorbidities and poor baseline health. However, the decision-making in those cases is rather complex and can be affected by many factors, including the surgeon’s decision, the patient’s suitability for endovascular intervention, patient and family choice, and severe hemodynamic instability [7,14]. Reports suggest that the median time from rAAA arrival to death in the nonsurgical group is 435 min, ranging from 15 min to 6 days [15]. Most vascular surgeons remember the awkward conversation they had with the patient and family a few days after telling them that the patient was not expected to survive the night. Knowing that at least three patients have survived such a rare event is important; however, this should be approached carefully.

Permissive hypotension is a well-known strategy used in the early management of major hemorrhages. However, in our patient, this was not pursued as the patient was placed on the end-of-life pathway, where vital signs were not routinely monitored. This principle is based on the concept that hypotension slows bleeding and allows clot formation and tamponade to prevent exsanguination. Aggressive fluid resuscitation can disrupt this tamponade effect by dislodging the clot and diluting clotting factors causing bleeding to resume [16]. Permissive hypotension allows a patient’s blood pressure to be maintained at the lowest level required for brain perfusion. As such, there is no set value to maintain a patient’s blood pressure; however, observations from the IMPROVE trial have suggested that the previously recommended threshold of 70 mmHg may be too low [17]. Interestingly, they also found that patients undergoing EVAR with local anesthesia had a significant 4-fold survival benefit compared to those treated with general anesthesia for EVAR. This may be related to the substantial hemodynamic compromise that comes with general anesthesia and the loss of the tamponade effect [17]. Although the present case was related to the operative management of rAAA, the question arises as to whether we can treat patients who are not fit for surgery in a similar manner.

A conservative, medically driven pressure control is a well-recognized approach in thoracic “acute aortic syndrome.” In those cases, surgical intervention is reserved for cases of active bleeding and/or organ hypoperfusion. However, Namai and Sakurai [18] reported a case of conservative treatment for a ruptured thoracic aortic aneurysm with strict blood pressure control and no surgery. Despite the differences between the thoracic and abdominal aortas with respect to the underlying pathology, flow dynamics, and tamponade mechanism, the medical component of this approach might apply to the abdominal aorta, at least in selected cases. This approach comes with a few challenges, including specific patient selection criteria, individualization of the optimum blood pressure range, the definition of care ceiling, and how close the cases should be monitored.

There is an increasing emphasis on shared decision-making and involving patients in these crucial decisions in advance. Advanced care planning with a view toward palliation in older patients with incurable diseases and those who are at risk of sudden death from their condition is highly recommended [19]. Davies et al. [20] recently highlighted the limited application of these principles in patients with AAA. Many patients who had such discussions were primarily admitted to emergency hospitals. The authors suggest that patients with inoperable aneurysms should receive a dedicated consultation where aspects such as the preferred place of care and death can be discussed and documented with the involvement of family members. It would be more beneficial to have these discussions with patients in advance rather than at the time of rupture.

Clearly, four cases of rAAA survival are not enough to justify a whole new approach to the rAAA conservative pathway, but they raise the question about the need for an individualized, more aggressive monitoring and support pathway, at least in patients who survive for more than 24 hours on conservative treatment. Obviously, the numbers will be too low for any single unit to investigate this potential approach but a combined registry or prospective database looking into this group might become an option in the future as the number of older patients “outside the scope of the available evidence-base” is increasing; hopefully, the incidence of reporting of such cases will increase with more awareness of this possible outcome.

In summary, although nonsurgical management of rAAA is still used in a significant proportion of patients, survival after conservative treatment is extremely rare. However, this rare event could occur unexpectedly, and the mechanism by which this occurs is not yet fully understood. With an increasingly aging and frail population, it is vital to explore this further, aiming to improve mortality and quality of life in the nonsurgical management of rAAA.

None.

The authors have nothing to disclose.

Concept and design: all authors. Analysis and interpretation: all authors. Data collection: all authors. Writing the article: all authors. Critical revision of the article: SSS, MGBH. Final approval of the article: all authors. Statistical analysis: None. Obtained funding: None. Overall responsibility: MGBH.