Acute dissection is a uniquely complex, relatively common, and frequently lethal aortic catastrophe. Historically, surgical treatment has been reserved for cases with complications including rupture; the results have been less than optimal because of excessive morbidity and mortality. This is the main reason why conservative management emerged as the standard of care for management of acute type B aortic dissection (TBAD). While more patients would appear to survive with a conservative treatment strategy, the outcome in terms of 30-day mortality (20%) and occurrence of late complications - such as enlarging aneurysms of the thoracic false lumen (30-40%) - leaves (again) much to be desired. Stent-graft endovascular repair has emerged as a very promising, less invasive treatment option. These devices, when used appropriately, can achieve the important therapeutic goals of entry-site coverage, depressurization of the false lumen, and expansion of the compressed true lumen - overcoming ischemic (malperfusion) manifestations. The early results of stent-graft repair of TBAD are encouraging, and even exciting, but much more work needs to be done in various critical areas surrounding this condition. Thoracic endograft technology has lagged behind its abdominal counterpart. The design of acute dissection-specific devices is imperative, reflecting the significant differences between TBAD and degenerative thoracic aortic aneurysm disease. Needs for this and other important developments notwithstanding, it is generally acknowledged that stent-graft intervention does represent an important advance in the treatment of patients with TBAD. Well-designed, controlled clinical trials will be necessary to elucidate the relative value of several endovascular thoracic strategies.