Background The US Food and Drug Administration approved the first thoracic aneurysm endograft in 2005. However, because the United States lacks a thoracic aneurysm endovascular repair registry, implications of Food and Drug Administration endograft approval on surgical management of thoracic aneurysms in clinical practice are unknown. Methods Retrospective review of thoracic aneurysm repair rates for 2000 to 2007 and analysis of patient characteristics and complications for 2006 and 2007 cohorts uses the National Inpatient Sample. International Classification of Diseases, 9th Revision codes were used to identify unruptured descending thoracic aneurysm cases undergoing either thoracic endovascular aortic repair (39.73) or open repair (38.45). Results Thoracic aneurysm open repair averaged 3.3 per million from 2000 to 2002 and increased to 5.6 per million in 2003 with introduction of 16 slice computed tomographic scanners. In 2005 endovascular repair was 1.2 repairs per million, which increased dramatically to 6.1 repairs per million in 2006. In 2007, endovascular repair decreased to 4.8 repairs per million while the open repair rate was 3.1 repairs per million. The 2006 and 2007 open repair cohorts had more favorable baseline characteristics compared with the endovascular cohort. Open repair mortality was significantly greater than endovascular mortality in 2006 (estimated relative risk, 8.48; 95% confidence interval 3.03 to 23.75), but not in 2007 (estimated relative risk, 0.71; 95% confidence interval 0.12 to 4.24). Length of stay was greater for open repair in 2006 and 2007. Conclusions Thoracic endovascular aortic repair has been rapidly adopted in the United States resulting in increased treatment of thoracic aortic aneurysms. Despite older age and comorbidities, endovascular repair had better outcomes and shorter hospital stays. © 2010 The Society of Thoracic Surgeons.