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Objectives: Ruptured abdominal aortic aneurysm (RAAA) is associated with high morbidity and mortality. We evaluated our single-center experience with management of patients with RAAA.Methods: We reviewed our experience using a clinical research/quality improvement database with a historical cohort study design. Risk and diagnostic factors were assessed using only preoperative data. Longterm follow-up was completed by clinical contact and national death index. Data were analyzed by univariate and multivariable methods for discrete, continuous and survival data structures. Analyses were performed using SAS 9.4 software.Results: Between 2001 and 2016, we repaired 610 AAAs, of which 153 (25%) were RAAA. Patients with RAAAs were younger (median age, 70 vs 72 years; P < .003), mostly male (80% vs 20%; P ¼ .279), and 86.3% vs 21% (P < .001) were transferred from other facilities. RAAA patients commonly presented with diaphoresis (15.7% vs 1%; P < .001), hypotension (52% vs 1%; P < .001), pulsatile abdominal mass (12% vs 5%; P < .002), acute abdominal pain (82% vs 30%; P < .001), acute back pain (43% vs 16%; P < .001), or syncope or dizziness (23% vs 4%; P < .001) on admission. RAAA patients had more high-grade atheromatous disease (8% vs 2%; P < .001), mycotic aneurysm (5% vs 1%; P < .008), with greater median aneurysm size (8 vs 5.5 cm; P < .001). Women ruptured at a lower aortic size than men (7.4 vs 8.1 cm; P < .061). The 30-day death rate was 22% in rupture vs 4% in nonrupture (P < .001). In the RAAA subcohort, predictors of 30-day mortality were age >70 years (P < .04), glomerular filtration rate (GFR) <60 (P < .001), and hypotension (P < .042). No rupture patient died who did not have at least one of these risk factors (P < .001), and these were deemed high risk. Over a mean followup time of 7.7 years, long-term survival at 1 and 5 years was 66% and 54% among RAAA managed with open repair, compared to 84% and 72% among RAAA managed with endovascular repair, and 90% and 73% among nonruptured AAA (P < .001, Fig) . In multivariable Cox regression, adjusted for age >70 years, rupture, chronic obstructive pulmonary disease and low GFR, EVAR was associated with a 1.5-fold reduction in hazard of long-term mortality (P > .0458). In adjusted multivariable analysis (adjusting for rupture and high-risk presentation), EVAR was associated with a 2.8-fold reduction in 30-day mortality (P < .008).Conclusions: Age >70, GFR <60 and hypotension were highly predictive of mortality in RAAA. EVAR was associated with reduced mortality and had favorable long-term outcomes even among high-risk population.