going to correct you OP, this is the third AO game rated for extreme violence, after manhunt 2 and thrill kill iirc
Technically speaking there are only two released ao games because of violence. Thrill Kill was issued the ao rating, but it was never released officially so I wouldn't exactly count it for released ao games.
Maybe it's just me, but this just doesn't seem as violent as everyone is making it to be. The parts I see people talking about a lot are where the main character is finishing off the innocent bystanders which were graphic I'll, but the actual gameplay is really just a top down shooting down innocent people unless there's more parts to it that I wasn't informed about.
Or maybe I'm heartless or dumb I don't know, but I feel like this really just should've gotten a M rating at most.