Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.