Four randomized clinical trials prospectively compared endovascular (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA): Chronologically these are EVAR 1 (UK), DREAM (Netherlands), OVER (USA) and ACE (France). All of them investigated whether the superior early postoperative outcome of endovascular repair is maintained in the long-term. The longest follow-up data of EVAR 1, with a mean person-years observation (either until death or end of study) of 8 years, clearly question the superiority of EVAR. In this context, open repair of AAA takes on a new significance and the indication for endovascular repair should be critically assessed with regard to the long-term course. Indication for invasive treatment has not changed and should - apart from exceptions - only be given for men with a diameter of 5,5 cm or more. Furthermore, current studies on prophylactic mesh reinforcement after open repair of AAA show that incisional hernias can be safely avoided.