In patients presenting with a ruptured abdominal aortic aneurysms (AAA), a choice can be made whether or not to offer treatment (selective treatment policy). Patients with a realistic expectation of survival after surgery, identified by several available prediction models, can be offered two treatment options: conventional "open" surgical repair and endovascular "minimally invasive" repair. Conventional open repair carries a significant morbidity and mortality, due to the combined effects of general anaesthesia and surgical exposure. Based on anatomical criteria assessed on a pre-operative CT angiography scan, approximately half of the ruptured AAA are suitable for endovascular aneurysm repair (EVAR). The majority of comparative studies show a clear trend towards lower perioperative mortality for endovascular repair compared to open surgery. The overall analyses of EVAR compared to open surgery, taking one randomised controlled trial and 23 available observational studies into account, showed a 38% decrease in 30-day or hospital mortality rate (Peto odds ratio 0.62; 95% CI 0.52 to 0.74). However, these mainly observational studies show considerable heterogeneity. Furthermore, potential selection bias, selecting patients for endovascular repair constituting a haemodynamically lower-risk category with a more favourable EVAR suitable anatomic configuration, makes a proper comparison unlikely. Therefore, randomised controlled trials, although difficult to perform in an acute severe condition like ruptured AAA, are needed to identify possible benefits of EVAR over open surgery in patients with a ruptured AAA.