Ascending thoracic aortic aneurysm (ATAA) is a permanent and irreversible dilatation of the thoracic aorta. Many patients remain asymptomatic until acute presentation with rupture or dissection (AD), which is associated with a 50% early mortality rate. The evolution in our understanding of the disease from large observational studies has led to the reliance on ATAA maximum diameter as the primary predictor of future rupture, currently used as clinical standard for elective surgery. Recent literature, however, has shown that this parameter alone cannot be considered a reliable predictor of rupture risk, because it fails to take into account the well-established multiple factors involved in ATAA pathophysiology, including local blood flow patterns, aortic wall mechanical properties and wall structure.