Ascending Aortic Aneurysms: From Pathophysiology to Surgical Repair

The aorta, once viewed as a passive conduit, is now recognized as an active organ crucial for hemodynamic regulation and vascular homeostasis. Thoracic aortic aneurysms (TAAs), particularly those involving the ascending aorta, often remain silent until life-threatening complications such as dissection or rupture occur. Current management primarily relies on aortic diameter criteria, yet up to 60% of type A dissections occur at sizes below the 5.5 cm surgical threshold, revealing the limitations of this approach. This narrative review summarizes recent advances in understanding ascending aortic aneurysms, including insights into their genetic and degenerative mechanisms, the role of novel morphological and hemodynamic markers, and the potential of advanced imaging techniques. It also explores evolving surgical strategies, from conventional open repair, still the gold standard, to minimally invasive and investigational endovascular approaches. By integrating biological, morphological, and clinical factors, emerging strategies aim to move beyond diameter alone toward more personalized risk assessment. This paradigm shift may improve early detection, optimize surgical timing, and ultimately enhance outcomes for patients with ascending aortic aneurysms.