It is estimated that an AAA will ruptured freely anteriorly into the intraperitoneal cavity in about 20 % of cases. Usually, this will manifest as sudden severe abdominal or back pain with cardiovascular collapse. Often, the clinical picture is that of a patient found down with hypotension and a distended abdomen. Intraperitoneal rupture will result in rapid exsanguination into the peritoneal cavity as it is a large space without the potential of localized tamponade. In the majority of cases, the patient expired prior to reaching medical care [3]. For those that are fortunate enough to reach medical care, rapid and effective aortic control is the patient’s only chance of survival. The use of aortic occlusion balloon has shown great promises as a method of aortic control, even in the emergency department resuscitation bay so that the patient can undergo definitive surgical treatment [16].

In the remaining 80 % of cases, the ruptured AAA is directed toward the retroperitoneal space, usually in the lateral posterior direction. In this classic presentation, the patient often experienced transient hypotension due to bleeding into the retroperitoneal space. Subsequent to the initial bleed, the localized effect of the retroperitoneal hematoma will temporarily tamponade and halt the hemorrhage. Typically, back/flank pain, transient hypotension, and syncope are the presenting symptoms. In the thin patient, the clinician can often palpate a pulsatile abdominal mass. The presence of blood in the retroperitoneal space can also lead to other uncommon clinical presentations such as groin pain, testicular pain, testicular or flank ecchymosis, iliofemoral DVT, or nephrolithiasis [3].

Despite the acute nature of ruptured AAA often leading to death within hours of presentation, a small subset of patients (4 %) can present with a chronic contained ruptured AAA. These patients typically have chronic back pain with radiation to the groin region. Other reporting symptoms can include lower limb weakness/neuropathy, lumbar vertebral erosion, and even obstructive jaundice [17]. In these patients, a high level of vigilance is required to make the correct diagnosis and offer the patient the appropriate surgical therapy.

In rare instances, the abdominal aorta can erode/rupture into the inferior vena cava with overall prevalence reported as 3–6 % of all ruptured aneurysms [18]. Clinically, the patient can present with the classic triad of abdominal pain, hypotension, and pulsatile abdominal mass with the addition of an abdominal bruit. These symptoms can be presented from as low as 17 % to as high as 90 % of patients based on the reported clinical series [18–20]. Other presenting symptoms can include high-output heart failure, angina, oliguria, fever, hematuria, and diminished lower limb pulses. Usually, the diagnosis is made at the time of surgery. If suspected, a contrast-enhanced CT scan is the imaging modality of choice. Loss of fat plane, effacement of the IVC, and direct contrast flow into the cava are typical findings. Endovascular repair is preferred over open surgical as open aneurysm repair can result in massive blood loss from the cava upon entering the aneurysm sac [20].

Rare cases of aorta to the left renal vein and aorta to the duodenal erosion/rupture have been reported in the literature [7]. In the case of erosion into the left renal vein, hydronephrosis, hematuria, and previous history of aortic surgery should alert the clinician to the diagnosis. Erosion into the bowel usually occurs in those individuals with prior aortic replacement surgery rather than as the initial presentation of a ruptured AAA. In the case of an aortoduodenal fistula, the patient will often present with a “herald bleed” of either upper or lower GI in nature. The presence of GI bleeding in any individual with a history of prior aortic surgery should prompt the clinician to rapidly workup the patient with an abdominal CT scan looking for obliteration of the fat plane between the aorta and the third portion of the duodenum. Upper GI endoscopy can also be helpful as it is specific but not sensitive. A high index of suspicion and prompt surgical intervention are critical to salvage these patients.