98.8%]) and OSR (100%, P Ͼ .05). The 5-year all-cause survival was significantly reduced in the EVAR group (50.4%, 95% CI, 34%-66%.) vs OSR (80.4%, [95% CI, 66.9%-89.5%; P ϭ .0279; h, 0.34 [95% CI, 0.12-0.94]). However, none of the deaths in the EVAR group were aneurysmrelated. The 30-day morbidity (P Ͻ .0001), length of hospital stay (P Ͻ .0001), 5-year quality-adjusted time spent without symptoms of disease and toxicity of treatment (P Ͻ .01), and cost per QALY (P Ͻ .01) were all significantly reduced with EVAR compared with OSR.Conclusions: Endografts can be effectively used to treat difficult pararenal AAAs, with enhanced long-term aneurysm-related survival, cost-effectiveness, and quality of life, and with significantly reduced perioperative morbidity, mortality, and waiting time from diagnosis to treatment.