The care of the patient with thoracic aneurysms is quite complicated. The decision to treat an aneurysm must be based on the risk of rupture and the patient's life expectancy. The preoperative evaluation must include detailed imaging to allow proper preoperative planning. This is especially important to determine the need for hypothermic circulatory arrest or the potential to treat a descending aneurysm with an endovascular approach. Thorough preoperative preparation and intraoperative care are as important as surgical decision making and meticulous technique. Although significant advances have been made in operative approaches, cerebral and myocardial preservation, and postoperative care, the management of complicated aneurysms of the thoracic aorta is frequently a humbling experience.