OBJECTIVES: To evaluate the cost-effectiveness of endovascular repair (EVAR) compared to Open Surgery (OSR) for the treatment of Abdominal Aortic Aneurysms (AAA) from the Italian NHS' perspective. METHODS: A Markov model was designed to estimate the clinical and economic consequences of EVAR and OSR after one year. The base case scenario refers to the treatment of 70-year-old patients with AAA > 5.5 cm who are medically suitable to undergo either OSR or EVAR. In the model, patients move from one health state to another within 3- month cycles. Transitional probabilities of the two treatment options, including mortality and complications, as well as utilities were derived from published sources. Cost input variables like resource utilization during the procedure, treatment of post operative complications and cost of follow-up were estimated based on data made available by a panel of Italian experts. RESULTS: Total direct NHS costs were €15.858 and €12.289 for EVAR and OSR, respectively. QALYs were 0.779 and 0.651 (EVAR vs OSR, respectively). Results were evaluated at a 1-year timeframe. The difference of costs due to systemic complications is favorable to EVAR (€290/patient), whilst costs for EVAR-specific complications, like conversion to OSR, endoleak, rupture or endovascular graft adjustment after migration, amount to €854/patient . The ICER for EVAR vs OSR was estimated at €27.809/QALY. Improvements in QoL, decrease of operative death and reduced post operative complications with EVAR led to greater total QALYs vs OSR. Sensitivity analysis confirms base case scenario. CONCLUSION: EVAR is a valuable alternative to OSR in 70 years old patients with AAA > 5.5. Efficacious without compromising QoL and with a safety decreasing the operative death, EVAR can be considered a cost-effective procedure for AAA in Italy.