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Endovascular aneurysm repair (EVAR) can be performed through percutaneous or surgical access. Our goal was to assess the difference in perioperative outcomes based on access type in a real-world setting.The Vascular Quality Initiative (VQI) database was queried for EVAR. Univariable analysis and multivariable analysis were used to determine the independent effect of access type.There were 8340 (64%) and 4747 (36%) EVAR procedures performed through percutaneous and surgical access (3395 [72%] transverse and 1352 [28%] vertical incisions). In 347 cases (4%), percutaneous access failed. Percutaneous access was performed more in patients who were younger and male, had higher body mass index, were nonsmokers, and had commercial insurance. Multivariable analysis showed that surgical transverse compared with percutaneous access was associated with more cardiac complications (odds ratio, 1.53; 95% confidence interval [CI], 1.14-2.05; P = .005), prolonged operative time (means ratio [MR], 1.25; 95% CI, 1.23-1.27; P < .001), larger estimated blood loss (EBL; MR, 1.51; 95% CI, 1.45-1.57; P < .001), and length of stay (LOS; MR, 1.28; 95% CI, 1.23-1.32; P < .001). Open surgical access through vertical incisions compared with percutaneous access was associated with prolonged operative time (MR, 1.34; 95% CI, 1.31-1.37; P < .001), larger EBL (MR, 1.67; 95% CI, 1.58-1.77; P < .001), and LOS (MR, 1.49; 95% CI, 1.42-1.57; P < .001). Open access through a vertical incision compared with a transverse incision was associated with prolonged operative time (MR, 1.07; 95% CI, 1.04-1.1; P < .001), larger EBL (MR, 1.1; 95% CI, 1.04-1.18; P = .001), and LOS (MR, 1.17; 95% CI, 1.1-1.23; P < .001). Failed percutaneous access was seen more with previous bypass, ruptured aneurysm repair, general anesthesia, female sex, obesity, coronary artery disease, and preoperative aspirin use. Failed percutaneous access was associated with increased cardiac complications (odds ratio, 2.48; 95% CI, 1.38-4.6; P = .003), prolonged operative time (MR, 1.64; 95% CI, 1.56-1.72; P < .001), larger EBL (MR, 3.27; 95% CI, 2.95-3.62; P < .001), and longer postoperative LOS (MR, 1.47; 95% CI, 1.35-1.6; P < .001). There was no independent effect of access type on respiratory and lower extremity ischemic complications or mortality.The rate of percutaneous access in this contemporary series is higher than historically reported. Percutaneous access is associated with decreased operative time, EBL, and LOS and should be considered when possible. For open surgical access, transverse incisions are associated with lower operative time, EBL, and LOS. Failed percutaneous access is associated with higher cardiac complications as well as with operative time, EBL, and LOS. Extra caution should be used with patients at high risk for failed percutaneous access. Further prospective investigation is needed incorporating details about the quality of the access vessel to determine the interactions of these risk factors.