A review of the clinical spectrum observed during the aggressive surgical treatment of 43 ruptured abdominal aortic aneurysms in a rural community hospital by one surgeon over 10 years is presented. Diagnosis frequently was delayed by other considerations. Although the patients had an average age of 70 years and 77% presented in shock, aggressive surgical treatment resulted in a 61% rate of survival with minimal complications. Prompt aortic control, graft replacement, and vigorous supportive care are required for successful treatment of this lethal and common abdominal emergency.