As the population ages, the rate of identification and repair of complex aortic pathology in patients of advanced age is rising. The older adult patient, defined here as 80 years or older, presents unique challenges for aortic repair due to medical comorbidities, declining functional status and independence, and anatomic changes. In this review, the evidence-based risk assessment and perioperative management are discussed, including the use of geriatric assessment tools, frailty indices, and emerging prehabilitation strategies. Outcomes for both open and endovascular procedures are examined, with a focus on more complex repairs, such as fenestrated and branched repair for paravisceral and thoracoabdominal pathology. Finally, ethical and social considerations, such as shared decision making, expectation management, and cost are addressed. Careful patient selection and individualized optimization is critical for successful aortic repair in this vulnerable patient population, with the goal of minimizing morbidity and loss of independence without compromising outcomes.
