BACKGROUND The rupture risk of abdominal aortic aneurysms (AAAs) depends primarily on their diameter and increases exponentially with aneurysm growth. Therefore, giant AAAs, defined as > 13.0 cm in diameter, are rare clinical entities. METHODS A giant ruptured AAA that measured >20 cm in diameter was successfully treated by open repair. CONCLUSIONS It remains unclear why giant AAAs continue to grow to extreme size without rupturing. Open repair seems to be the treatment of choice for most giant aneurysms, both ruptured and unruptured.