During the past 50 years, the genetic basis and natural history of aortic disease has been defined. Surgical methods evolved to reduce mortality and morbidity from bleeding, renal impairment, cerebral injury, and paraplegia. Aortic surgery is now a specialty in itself. Experienced groups achieve a mortality rate of less than 2% for root operations and less than 15% for arch surgery and aortic dissection. The introduction of stent grafts has changed the approach to vascular pathology. These are less intimidating for the patient but have unsolved risks with uncertain long-term outcome. In the future, an evidence-based balance between conventional surgical procedures versus interventional strategies is required.