BACKGROUND Acute aortic dissection (AAD) is one of the most common aortic emergencies that vascular specialists are asked to manage. Traditional surgical interventions for cases complicated by malperfusion have resulted in significant morbidity and mortality. With increasing availability of thoracic endografts, endovascular interventions for complicated AAD have become more acceptable. We reviewed our experience with endovascular treatment of AAD since January 2005. METHODS Medical records of patients admitted for AAD from January 1, 2005, to December 31, 2008, were entered into our vascular registry and analyzed for risk factors, extent of dissection, type of management, fate of the false lumen, complications, and survival. There were 249 admissions for aortic dissections during the study period. Our study group included 28 patients with complicated AAD who underwent endovascular intervention. RESULTS During the study interval, 28 patients (16 male) underwent 44 procedures. The average age was 54 years. Risk factors differed from the typical atherosclerotic patient and were dominated by an 89.3% incidence of hypertension. Five patients (17.9%) presented with a history of recent cocaine use. The average length of stay was 25.1 days (range, 1-196 days). Stanford type B dissections were present in all but one patient. Twenty-six thoracic endografts were placed in 25 patients. Eight patients required multiple procedures in addition to a thoracic endograft. Morbidity occurred in 17 (60.7%) patients, with renal insufficiency occurring in 11 patients (39.3%) and one requiring permanent dialysis. Four neurologic events occurred: three strokes (10.7%) and one patient (3.6%) with temporary paraplegia. Three patients (10.7%) died in the periprocedural period, with ruptured dissection in one and pericardial tamponade in another. Eight of 10 computed tomography scans (80%) available for review in follow-up showed complete thrombosis of the thoracic false lumen. CONCLUSIONS Complicated AAD remains a challenging problem, with significant morbidity and mortality rates. However, our early experience with endovascular management offers a favorable reduction in mortality from historic controls.