The management of thoracic aortic disease is based upon the aortic pathology and anatomy. The thoracic aorta is evaluated in four separate segments: the aortic root, ascending aorta, transverse arch, and descending aorta. In addition to the aortic disease, factors that affect the timing and extent of surgical replacement of the thoracic aorta include the presence of aortic valve pathology, concomitant cardiac disease, and the patient's age and comorbidities. This chapter will review the most common indications for treatment of diseases of the thoracic aorta and the perioperative care of patients undergoing aortic surgery.

The most common indications for surgery on the thoracic aorta, in descending order, are aneurysmal disease, acute aortic syndromes, trauma, and infection. The incidence of thoracic aortic aneurysms is estimated to be 5.9 cases per 100,000 person-years, and replacement of the ascending aorta accounts for the majority of thoracic aorta procedures. The most common causes of thoracic aortic aneurysms (TAAs) are cystic medial necrosis; atherosclerosis; heritable connective tissue disorders (e.g., Marfan syndrome); familial, bicuspid aortic valve disease; and chronic aortic dissection. The presence or absence of symptoms is the most important factor in the management of patients with thoracic aortic aneurysms. Patients with symptomatic TAAs typically experience chest or back pain, depending upon the location of the aneurysm. The sudden onset of pain is considered an ominous warning sign of imminent rupture or dissection, and surgery is indicated for all patients with symptomatic TAAs.