OBJECTIVE Cocaine use can result in a variety of cardiovascular complications, including myocardial infarction, arterial thrombosis, coronary dissection, and cardiomyopathy. Cocaine-induced aortic dissection is uncommon and has been described largely in case reports. The purpose of this study was to review our experience with aortic dissection associated with cocaine abuse. METHODS A retrospective chart review was performed of all hospital records during a 15-year period in patients diagnosed with aortic dissection. Among the 164 cases of acute aortic dissection, 16 patients (9.8%) had used cocaine or its derivative, crack cocaine, within 24 hours prior to the onset of symptoms. The remaining 148 patients (90.2%) had no history of cocaine usage. Clinical features, management, and outcome in these two groups were compared. RESULTS In the cocaine group, powder cocaine was inhaled intranasally in 11 patients (69%) and crack cocaine was smoked in five cases (31%). The mean duration between cocaine use and the onset of aortic dissection was 12.8 hours (range, 4 to 24 hours). Patients in the cocaine group were younger in age and more likely to have a history of polysubstance abuse than the non-cocaine cohort. In the cocaine group, the incidence of DeBakey dissection type I, II, IIIa, and IIIb was 19%, 25%, 38%, and 19%, respectively. In the group without cocaine use, the incidence of DeBakey dissection type I, II, IIIa, and IIIb was 18%, 23%, 39%, and 20%, respectively. Surgical intervention for aortic dissection was performed in 50% of the cocaine group and 45% of the non-cocaine group. In patients who underwent surgical repair, greater pulmonary complications occurred in the cocaine group than the non-cocaine group (n = 0.02). No difference was noted in the hospital length of stay or 30-day operative mortality among the two groups. CONCLUSIONS Cocaine-associated aortic dissection occurs in predominantly male patients with illicit drug abuse who were younger than patients with aortic dissection without cocaine use. Greater pulmonary complications can occur in patients with cocaine-related aortic dissection following surgical interventions.