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Purpose: To assess mortality and treatment costs of a new management protocol with preferential use of emergency endovascular aneurysm repair (eEVAR) for acute abdominal aortic aneurysm (AAA)., Methods: From September 2003 until February 2005, 49 consecutive patients (45 men; mean age 71 years) with acute AAA were entered into a prospective study of a new management protocol that featured preferential use of eEVAR (n=18); patients with unsuitable anatomy or who were hemodynamically unstable underwent open repair (n=31). Mortality data and costs of treatment were compared in this mixed prospective group to a historical control group consisting of 147 patients (128 men; mean age 71 years) who underwent open repair from January 1998 to December 2001. All direct medical costs were included from the moment of admission until discharge from the hospital., Results: Mortality in the mixed prospective group (18%) was lower than in the historical control group (31%), but the difference did not reach statistical significance (p=0.099). The mean total cost in the mixed prospective group was 17,164 euro compared to 21,084 euro in the historical open repair group (p=0.255)., Conclusion: A preferential eEVAR protocol for acute AAA can decrease mortality and does not increase overall costs during initial treatment, but larger studies are needed to determine if these trends are statistically significant.