Acute aortic syndrome are emergent life-threatening conditions of the thoracic aorta presenting with abrupt onset of severe pain and may often be associated with neurological symptoms and signs of end organ or limb malperfusion. These conditions include Stanford Type A and B aortic dissection, intramural hematoma, penetrating aortic ulcer, and blunt thoracic aortic injury. Aortic dissection is most frequent (62–88%), followed by intramural hematoma (10–30%) and penetrating aortic ulcer (2–8%). Clinical suspicion for acute aortic syndrome with immediate diagnostic testing is necessary for diagnosis and treatment with diagnostic modalities of contrast-enhanced computed tomography, echocardiography, and magnetic resonance imaging. Initial management needs to be directed towards control of pain and blood pressure to reduce aortic wall stress, however there is a subset of patients who need immediate surgical intervention such as pathologies of the ascending aorta (i.e. Stanford Type A aortic dissection), complicated Type B aortic dissection, or grade 3 and 4 blunt thoracic aortic injury. There are indications for immediate surgical intervention for the other listed pathologies however the majority of the above can be treated initially with best medical management. Aside from the surgical treatment of the ascending aorta which usually necessitates open surgical repair, all other treatments can be treated with thoracic endografting (TEVAR), which has replaced open surgical repair with favorable outcomes. Studies have shown consistently that TEVAR is significantly less invasive, technically feasible with fewer complications having durable long-term results. Confirmed cases of acute aortic syndrome should be referred immediately to a high volume center and multidisciplinary team to determine need for medical management, endovascular intervention, or open surgery. Once the acute period is survived, regardless of the above treatments either surgical or medical, all acute aortic syndrome patients need lifelong medical and diagnostic surveillance to detect aortic degeneration and its complications.