Background: The endovascular treatment of abdominal aortic aneurysms has become more common. A careful comparison of this technique with the established treatment by open surgery is needed before it can be more widely adopted. Methods: We selectively searched the Medline database for articles on the endovascular treatment of abdominal aortic aneurysms, with special attention to prospective, randomized trials comparing it to open aortic surgery (keywords: "endovascular abdominal aortic repair" and "prospective randomized trial"). Results: Data on 30-day mortality and long-term survival are now available from four randomized multicenter trials. In three of these trials, endovascular treatment was found to lower 30-day mortality by two-thirds (endovascular: 0.2% to 1.7%, open repair: 0.7% to 4.7%), but this difference in survival was no longer present at two years. Compared to open open aortic surgery, endovascular treatment has a higher long-term complication rate. Endoleakage (perigraft leakage) accounted for more than 30% of complications and was the commonest reason for reintervention and unsuccessful intervention; in nearly all cases, it was successfully treated by the endovascular route. The rate of secondary aortic rupture was 0.8%, and migration of the prosthesis occurred in 5% of cases. Follow-up checks of the stent graft are now recommended at 3, 6 and 12 months after implantation, and annually thereafter. Conclusion: Prospective randomized trials have shown that the endovascular technique lowers perioperative mortality. In the long term, however, it has a higher complication rate than open aortic surgery and leads to more frequent reintervention.