Rupture remains a rare but morbid sequela of abdominal aortic aneurysm (AAA). Presentation highly varies, but rapid diagnosis and triage are key for mitigating mortality. Endovascular repair is increasingly used to treat ruptured abdominal aortic aneurysm (RAAA) owing to improved mortality, and planning should start early with CT imaging for all quasi-stable patients. Adjunctive strategies for perioperative management including permissive hypotension, balloon tamponade, and repair under local anesthesia should be employed in selected patients. Open surgical repair should be performed in patients not eligible for endovascular repair. Important concepts for open surgical repair include the approach (transperitoneal versus retroperitoneal), method of achieving proximal and distal control, use of heparin, and need for temporary abdominal closure. Postoperative care requires specific monitoring for abdominal compartment syndrome and ischemic colitis.