Observational studies comparing endovascular aneurysm repair (EVAR) with open repair (OR) in ruptured abdominal aortic aneurysms (AAA) have suggested a benefit for EVAR but have been questioned recently by randomized controlled trials (RCT). A low eligibility for endovascular repair is a main limitation of these RCTs. In contrast, data from 473 patients from 1998 to 2011 in the Örebro/Zurich series show that nearly all AAA patients presenting with rupture can in fact be treated with EVAR with a low 30-day mortality rate (24%) and a minimal exclusion rate (4%). By using different adjunct techniques, such as chimneys and periscopes, also juxtarenal aneurysms can be treated even if simultaneous aortic balloon occlusion is necessary. OnyxTM embolization of the internal iliac artery in patients with aortoiliac aneurysms prevents back flow, thus avoiding an endoleak type. From May 2009 until December 2013, 70 patients arrived at Örebro University Hospital with a ruptured AAA diagnose. Nine percent were considered unfit for any intervention (including OR) and were treated medically. All of the 64 patients that underwent surgery were treated with EVAR and 30-day mortality in this group was 17 of 64 patients (27%). The mortality for patients treated with adjunct techniques was not significantly increased compared with patients treated with standard EVAR. In conclusion, our data support that open repair of ruptured AAA can be replaced by EVAR with appropriate management of existing adjunct techniques.