Background: Abdominal aortic aneurysm (AAA) is a potentially fatal vascular condition that frequently presents with atypical features, creating diagnostic challenges particularly in primary and out-of-hours care settings. When ruptured, AAA carries a mortality rate approaching 80–90%, and delayed diagnosis significantly worsens outcomes. Objective: This narrative literature review examines the evidence on atypical AAA presentations, misdiagnosis rates, the role of screening and diagnostic tools, and the implications for primary care clinical governance and quality improvement. Methods: A structured search of PubMed, Cochrane Library, Scopus, and Web of Science was conducted covering literature published between March 2022 and December 2025. Search terms included 'abdominal aortic aneurysm,' 'primary care,' 'misdiagnosis,' 'rupture,' 'atypical presentation,' 'point-of-care ultrasound,' 'out-of-hours,' and 'screening.' Peer-reviewed studies, systematic reviews, clinical guidelines, and meta-analyses were included. Key Findings: Up to 39% of ruptured AAAs are initially misdiagnosed, with common mimics including renal colic, musculoskeletal pain, and urinary tract infection. Only 25–50% of patients with rAAA present with the classic triad of abdominal pain, hypotension, and pulsatile mass. Women, elderly patients, and those presenting to non-specialist settings are at particular risk of delayed diagnosis. Point-of-care ultrasound (POCUS) demonstrates sensitivity exceeding 98% and specificity of 99.84% for AAA diagnosis. Current NHS screening remains restricted to men aged 65, leaving women and younger high-risk individuals undetected. Conclusion: Improved diagnostic vigilance, expanded POCUS availability, enhanced telephone triage protocols, and inclusive screening policies are urgently needed in primary and out-of-hours care. Quality improvement programmes targeting AAA recognition should be implemented across urgent primary care settings.