Out of all types of chest trauma, thoracic aortic injury is perhaps the most lethal. Mechanisms of injury can either be penetrating or blunt. The majority of patients do not survive the initial insult, and management of those making it to hospital is quite complex. Surgery used to be the mainstay of in-hospital management, although this has been superseded over the years by endovascular techniques. In this chapter, we discuss the mechanisms of traumatic aortic injury, early management strategies once transferred to hospital, decision-making for intervention, and predictors of long-term outcome.