Atheroembolism is an emerging problem in cardiovascular surgery, especially in elderly patients. Severe atherosclerosis of the thoracic aorta usually reflects systemic atherosclerosis. Aggressive preoperative and intraoperative evaluation of the aorta using enhanced CT, transesophageal echocardiography and epiaortic ultrasound is important in elderly patients as well as those with systemic atherosclerosis. To prevent atheroembolism, it is important to select an adequate arterial perfusion site and to avoid touching the diseased aorta until circulatory arrest. In atherosclerotic aortic arch aneurysm, central cannulation under ultrasound guidance and directing the dispersive cannula toward the aortic root is a simple and effective perfusion strategy. Axillary perfusion is useful as an alternative to central cannulation in atherosclerotic aortic disease, but special care is necessary to avoid complications when the patient has a small axillary artery or flail atheroma around the arch vessels. In femoral artery perfusion, retrograde perfusion may induce paradoxical cerebral embolism, but the incidence of stroke is comparable with axillary perfusion when there is adequate preoperative screening using transesophageal echography. Circulatory arrest with/without cerebral perfusion is another important strategy when the aorta has severe atherosclerosis. Recent literature has shown that mild hypothermia may be safe for anterior cerebral perfusion during circulatory arrest, but optimal flow rates and time limitations are unknown. A simple calcified aorta called "porcelain aorta" may be managed by circulatory arrest, local debridement and the clamp method. Several surgical options are proposed for this clinical entity but their use will diminish in the future because of transcatheter valve replacement.