Background: Thoracic endovascular aneurysm repair (TEVAR) has been rapidly introduced as a primary treatment modality for thoracic aortic diseases with limited data available on midterm to late-term outcomes. Methods: A retrospective single institution study comparing hospital and midterm outcomes and costs for TEVAR versus open elective repair of descending thoracic aneurysms was conducted. Fifty-seven patients were included between 2005 and 2007 (TEVAR = 28; open = 29) and were followed until May 2010. Results: Patients in the TEVAR group were older (73.2 versus 62.3 years; p < 0.001). Hospital mortality was higher in the open repair group (10.3% versus 3.6%; p = 0.611). There was no statistical difference in stroke, paraparesis or paralysis, sepsis, or renal failure; however, a composite major adverse event variable showed a higher complication with open repair versus TEVAR (37.9% versus 14.3%; p = 0.043). Mean follow-up was 42.6 months for open repair versus 26.9 for TEVAR (p = 0.002). Kaplan-Meier survival analysis showed the initial survival benefit for TEVAR was lost in less than 6 months; however, the difference did not reach statistical significance during follow-up (log-rank test p = 0.232). Mean surveillance imaging costs for a TEVAR patient were $1,800.38 higher than for an open patient at 2 years. Compliance of TEVAR patients with follow-up imaging was 78%, 64%, 50%, and 42% at 1, 6, 12, and 24 months, respectively, and was even lower in those not registered in device trials. Conclusions: Patients in the TEVAR group had favorable early outcomes; however, midterm survival was reduced secondary to comorbidities. This study raises concern for the ongoing costs of surveillance imaging in TEVAR as well as patient compliance with follow-up. © 2012 The Society of Thoracic Surgeons.