High mortality and paraplegia rates associated with the surgical management of acute thoracic aortic ruptures limit its success. It was our objective to evaluate whether emergency endovascular interventions would improve the outcomes of these patients. Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with an endovascular stent graft. Medical records were reviewed for prehospital and emergency department data, operative findings, and outcomes. Patients were followed up at yearly intervals with high-resolution multidetector computed tomographic angiography. Perioperatively, there were 1 death (3.1%) among the 32 patients in the endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the surgical group. Three patients in the endovascular group had endovascular leaks develop that required reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery. Despite encouraging early outcomes, midterm results suggest a trend toward increased reintervention and late complication rates in the endovascular group. Therefore continued surveillance of patients treated with stent grafts is necessary.