Ruptured AAA for emergency EVAR under local anaesthesia81-year-old man, 74 kg, contained rupture of an infrarenal aneurysm on CT
Ruptured aneurysm: permissive hypotension and haemorrhage control under local anaesthesia
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Know this first
- Permissive hypotension: systolic 70–90 mmHg while he stays conscious.
- Local anaesthesia for EVAR avoids induction collapse and lowers mortality.
- Surgeons scrubbed and draped before any induction.
- Abdominal compartment syndrome: pressure over 20 mmHg with new organ failure.
The patient
The examiner asks
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Consider
What are your priorities?
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- An 81-year-old with a contained ruptured AAA on apixaban, for emergency EVAR under local. Patient
- At 81 I don't push his pressure as low as a young trauma patient's.
- ACC/AHA: this is emergency surgery, so no cardiac testing; his angina only shapes my targets. Disease
- Permissive hypotension: I accept a systolic of 70–90 if he remains awake and talking.
- Apixaban 6 hours ago adds to bleeding, so reversal is prepared now.
Plan
How will you manage him?
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- Local anaesthesia with minimal sedation: no induction collapse, and the abdomen keeps its tamponade. Surgery
- Surgeon's lidocaine kept within 4.5 mg/kg plain.
- Two large-bore cannulas, arterial line under local, blood in the room. Disease
- Crystalloid restricted; blood products instead, plasma to red cells close to 1:1.
- Andexanet 400 or 800 mg bolus then infusion; PCC if andexanet isn't available.
- Warmed products and calcium checked as he is transfused.
- Before any conversion, the surgeons must be gowned and the field draped. Surgery
Crisis
Mid-procedure he becomes grey and confused; BP 58/30, HR 132. What do you do?
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- Massive haemorrhage algorithm: free rupture with failing cerebral perfusion; protocol activated, surgeon told. (Crisis)
- Surgeon inflates an aortic occlusion balloon for proximal control.
- Field prepped and surgeons ready before I give anything, because induction will drop his pressure.
- Rapid sequence induction: etomidate 0.15–0.2 mg/kg for his age, rocuronium 1.2 mg/kg.
- Blood through the rapid infuser, plasma to red cells near 1:1; tranexamic acid considered.
- Calcium chloride 10 mL of 10%, as citrate lowers his calcium.
Crisis
In ICU the next morning, his peak airway pressure has risen to 38 cmH2O, urine output is 10 mL/h and his abdomen is tense. BP 96/58. What do you do?
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- Abdominal compartment syndrome is likely: measure his intra-abdominal pressure now. Crisis
- Over 20 mmHg with new organ failure confirms it; he had a balloon and massive transfusion.
- Medical steps: neuromuscular block, nasogastric decompression, no more crystalloid.
- Vasopressor to keep abdominal perfusion pressure above 60.
- Not improving: decompressive laparotomy without delay.
- Open abdomen with vacuum closure, aiming for early closure. After surgery
Fatal mistakes
- Fluid resuscitation to a normal blood pressure before control.
- Inducing general anaesthesia before the surgeons are ready.
- Missing abdominal compartment syndrome after rupture repair.
- No plan to reverse his apixaban.
Checked against: ESVS clinical practice guidelines on abdominal aorto-iliac artery aneurysms (2024) · Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: ASRA Pain Medicine evidence-based guidelines (fifth edition) (2025)
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