The Vienna Aneurysm Program in its present form developed in the late 80ies. The main focus at that time was on the conventional treatment of acute and chronic thoracic aortic pathology with a special focus on thoracic and thoracoabdominal replacement [1–7]. By the advent of endovascular therapy in the mid 90ies, a new option for the treatment of acute and chronic thoracic aortic disease became available [8–14]. Simultaneously, substantial experimental as well as clinical work was performed with the main focus on cerebral and spinal cord protection [15–18]. Finally, in 2003, the options of endovascular therapy were extended into the arch and even into the ascending aorta via newly developed vascular rerouting procedures [19–23]. As a next step, the first acute type A dissection was successfully treated by endovascular stent-graft placement in 2005 [24, 25]. Recently, a new mechanism of disease and consecutively, a new treatment approach of intramural hematoma affecting the entire thoracic aorta has been reported . The program has been steadily growing to a huge interdisciplinary group, encomprising cardiovascular surgeons as well as interventional radiologists. Overall, the numbers of patients presenting with aortic pathology are rising. Besides their usually advanced age, these patients suffer from significant comorbidities. Therefore, conventional aortic repair is associated with substantial risk. As a consequence, alternative approaches were warranted and have been developed to enable treatment of these patients. Combined approaches of various kinds have induced a change of mind in aortic medicine as the majority of patients today would have been refused any kind of treatment even a few years ago. Therefore, established limits have been transgressed. This article provides an overview of the current indications, surgical and endovascular approaches, results as well as a critical comment on all relevant issues concerning this exciting new field.