This handout is for acute aortic aneurysm + malperfusion in hypertensive emergency (anti-impulse + emergent endovascular/open repair). Your care team identified this based on: sudden severe back, flank, or abdominal pain in patient with known aaa or thoracic aneurysm + severe htn — suspect rapid expansion / contained rupture / branch malperfusion.
Other reasons your team may use this plan: cta showing aortic aneurysm (thoracic >5.5 cm or aaa >5.5 cm or rapidly expanding ≥5 mm/6mo) + intramural hematoma or contained rupture or branch malperfusion + severe htn; pulsatile abdominal mass on exam + new severe abdominal/back pain + severe htn — aaa expansion or rupture pathway; limb ischemia, mesenteric ischemia, aki, or paraplegia in patient with known aortic aneurysm + severe htn — branch malperfusion pathway.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| esmolol | 500 µg/kg IV bolus then 50 µg/kg/min infusion, titrate by 25 µg/kg/min q5 min to HR <60 (max 300 µg/kg/min) | IV | continuous | ACC/AHA 2022 Class I — anti-impulse FIRST; ultra-short half-life allows fine titration; HR <60 within 5-10 min target; same paradigm as dissection |
| labetalol | 20 mg IV q10 min (max 300 mg cumulative) OR 0.5-2 mg/min infusion | IV | bolus or infusion | ACC/AHA 2022 Class I alternative — mixed α/β provides combined HR + SBP control; useful when esmolol not on hand |
| nicardipine | 5 mg/h IV (ONLY after HR <60), titrate by 2.5 mg/h q5 min to SBP 100-120 within 20-30 min | IV | continuous | ACC/AHA 2022 Class I — add ONLY after esmolol/labetalol established HR <60; SBP target 100-120 (permissive hypotension) until proximal control achieved |
| nitroprusside | 0.25-10 µg/kg/min IV (ONLY after HR <60 with BB) | IV | continuous | Alternative vasodilator after BB; AVOID if eGFR <30 (cyanide); ACC/AHA 2022 acceptable adjunct |
| AVOID isolated vasodilator without BB | AVOID | N/A | N/A | Isolated vasodilator (nitroprusside, hydralazine, nicardipine without BB) increases dP/dt via reflex tachycardia → propagates aneurysm expansion / branch compromise (ACC/AHA 2022 Class III) |
| AVOID hydralazine | AVOID | N/A | N/A | Hydralazine causes reflex tachycardia → increases dP/dt → propagation |
| fentanyl | 25-100 µg IV q5-10 min titrate | IV | PRN | Pain control reduces sympathetic drive (HR + dP/dt); IV opioid preferred for rapid titration |
| massive transfusion protocol PRBC:FFP:platelets 1:1:1 | 6 units PRBC + 6 units FFP + 1 apheresis platelets initial pack | IV | continuous per blood bank protocol | Hemorrhage control bridge to surgical repair; 1:1:1 ratio per PROPPR (Holcomb JAMA 2015 PMID 25647203); permissive hypotension (SBP 80-90) until surgical control |
| TEVAR for descending thoracic aneurysm | Endovascular stent graft deployment per anatomy | procedural | one-time | IRAD precedent + INSTEAD-XL (Nienaber PMID 25840177) for thoracic descending; ACC/AHA 2022 Class I; CSF drainage protocol if T6-L1 for spinal cord protection |
| EVAR for abdominal aortic aneurysm | Endovascular stent graft deployment per anatomy | procedural | one-time | UK Trial (Greenhalgh PMID 16111932) + EVAR-1 (PMID 15978930) + DREAM (PMID 15469378) + OVER (PMID 19884600) — short-term mortality benefit over open repair for ruptured AAA; SVS 2024 + ESVS 2024 first-line for amenable anatomy |
| open repair for ascending aortic aneurysm or complex anatomy | Cardiothoracic or vascular surgical repair per anatomy | surgical | one-time | ACC/AHA 2022 Class I — open repair remains standard for ascending (mortality 50% if delayed); complex visceral anatomy beyond branched/fenestrated EVAR capability |
| CSF drainage protocol for T6-L1 endovascular | Lumbar drain pre-op + maintain CSF pressure <10 mmHg + MAP >85 for 48 h post-op | procedural | continuous 48 h post-op | SVS 2024 + ESVS 2024 — spinal cord ischemia prevention; reduces paraplegia rate from 5-10% to <2% |
| branch revascularization per malperfusion target | Covered stent, fenestration, or surgical bypass per branch (renal, mesenteric, lower extremity, spinal) | procedural | as needed | SVS 2024 + ESVS 2024 — restore branch flow within 6 h for mesenteric to prevent infarction; covered stent for renal; femoral-femoral bypass for lower extremity |
Plan: Acute aortic aneurysm + malperfusion — anti-impulse paradigm: HR <60 FIRST (BB), THEN SBP 100-120 (vasodilator). Permissive hypotension until proximal control. Emergent endovascular (TEVAR/EVAR) or open repair per anatomy.
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Lifetime aortic surveillance: post-EVAR/TEVAR CTA at 1, 6, 12 mo then annually (endoleak surveillance); for unrepaired remaining aneurysm sites q6-12 mo per size; lifelong BB ± ARB to BP <130/80 (ACC/AHA 2022); smoking cessation (strongest modifiable progression risk); statin per ASCVD; genetic counseling if Marfan/Loeys-Dietz/vEDS; family screening per USPSTF (AAA in 1st-degree male >65 ever-smoker); cardiac surgery follow-up if open repair
Guideline: 2022 ACC/AHA Aortic Disease Guideline (Isselbacher PMID 36066317) + SVS 2024 Abdominal Aortic Aneurysm Guideline + ESVS 2024 Abdominal Aortic Aneurysm Guidelines + 2025 ACC/AHA HTN Guideline + ESC/ESH 2024 HTN (Mancia PMID 38613493)