The term "acute aortic syndrome" describes a variety of acute and emerging aortic pathologies that include intramural hematoma, penetrating aortic ulcer and acute aortic dissection. However, the acute pathology of the thoracic aorta also includes the contained ruptures of aortic aneurysms, traumatic aortic ruptures and iatrogenic aortic dissections. In all these acute situations, in which emerging surgical treatment is often required, decision-making represents a crucial and extremely important phase, which often affects the patient's prognosis, in the short and long term. This review aims to present an update of the surgical treatment of acute aortic syndrome focusing mainly on the correct decision-making, the factors that influence it and the latest novel surgical techniques and strategies.