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Acute type B aortic dissection (ABAD) is a serious cardiovascular emergency in which morbidity and mortality are often related to the presence of complications at clinical presentation. Visceral, renal, and limb ischemia occur in up to 30% of patients with ABAD and are associated with higher in-hospital mortality. The aim of the open fenestration is to resolve the malperfusion by creating a single aortic lumen at the suprarenal or infrarenal level. This surgical procedure is less invasive than total aortic replacement, thus not requiring extracorporeal support and allowing preservation of the intercostal arteries, which results in decreased risk of paraplegia. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD, particularly for patients with no aortic dilatation. In the current endovascular era, this open technique serves as an alternative option in case of contraindications or failure of endovascular management of complicated ABAD.

Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.