Endovascular aneurysm repair (EVAR) has revolutionized the treatment of aortic aneurysmal disease. The mortality of EVAR patients in the perioperative period is less than open abdominal aortic aneurysm surgery (OAR), but this advantage is lost in follow-up. Long-term results demonstrate good durability in patients with suitable anatomy, but for those whose anatomy presents outside the instructions for use of the device, complications are very common. Additionally, long-term results suggest that past 10–15 years, the overall survival for EVAR patients may be inferior to open surgery. Thus, treatment recommendations for applying EVAR in patients with infrarenal aortic aneurysms should center on precise anatomic examination for device suitability and shared decision-making to the patient’s long-term goals.