Abstract The perioperative management of ruptured abdominal aortic aneurysms (RAAA) remains a core anaesthetic competency. Changes such as service centralization, aneurysm screening and the developing role of emergency endovascular aneurysm repair (EVAR) are altering the demands upon anaesthetists. Whereas previously on-site general anaesthesia for resuscitative open aneurysm repair (OAR) was standard, now transfer, choice of surgical technique and options for anaesthetic management may need to be considered. We present the key components of emergency anaesthesia for both OAR and EVAR and describe clinical dilemmas arising at preoperative and intraoperative stages.