A 59-year-old female smoker with a history of hypertension and hypercholesterolaemia was admitted to the emergency department (ED) with a 24-hour history of sudden-onset and severe stabbing chest pain radiating to the interscapular region. Hypertension and hypercholesterolaemia were treated by her primary care physician with a beta-blocker, a thiazide, and a statin. Her right brachial blood pressure upon admission was 151/97 mmHg without significant right/left difference. A regular heart rate of 87 bpm, an oxygen saturation of 91%, and a temperature of 36.0°C were noted. Intravenous opioids were administered to control her pain. Physical examination was normal except for bilateral basal crepitations. Arterial blood gas showed a respiratory alkalosis (pH 7.46) with a decreased pO2 (64 mmHg), a decreased pCO2 (32 mmHg), and a normal HCO3 (22 mmol/L). Electrocardiogram showed signs of left ventricular hypertrophy with a Sokolow index > 35 mm without signs of cardiac ischaemia or ST elevation. An urgent computed tomography angiography (CTA) revealed a RAArch with an ALSA arising from KD with a type B aortic dissection extending from the ALSA to the level of the diaphragm together with a peri-aortic hematoma and a right-sided haemothorax without any active contrast extravasation (). The patient was admitted to the intensive care unit (ICU) for aggressive blood pressure control using intravenous beta-blockade. Echocardiography showed no structural nor valvular heart disease with a normal cardiac function and no pericardial effusion. The patient was discussed within the local multidisciplinary aortic team, and there was decided to perform a semi-urgent repair to treat this acute type B dissection with a peri-aortic haematoma and right-sided haemothorax. Due to the semi-urgent need for repair, there was opted for a hybrid repair, which was also influenced by the patient’s choice, who preferred not to have open aortic surgery despite her young age, and the fact that she was a physically unfit active smoker. Pre-operatively, a spinal drain was placed. In the hybrid room, bilateral radial arterial lines, a central venous catheter, and a rapid pacing electrode were introduced through the left femoral vein. An arch angiogram demonstrated a dominant right vertebral artery. Hence, a right-sided carotid-subclavian bypass was performed (Gelsoft plus 6 mm, Terumo, Vascutek Ltd, Scotland, UK) followed by stent-grafting (31-31 200), the entire descending thoracic aorta covering the ostia of both subclavian arteries to land 3 cm above the celiac trunk (GORE® TAG® Conformable Thoracic Stent Graft with ACTIVE CONTROL, W.L. Gore & Associates, Flagstaff, USA). The ALSA was occluded with an Amplatzer plug 12 mm (Abbott vascular, Diegem, Belgium) via the left brachial artery just distal of the KD. Completion angiogram showed bilateral patent common carotid arteries and right-sided carotid-subclavian bypass, and aortic remodelling without any flow in the KD. Because of severe ischaemia of the left arm and hand, a left sided carotid-subclavian bypass was performed (Gelsoft plus 6 mm) during the same procedure (). The postoperative course in ICU was complicated with a respiratory infection requiring intravenous antibiotics, ventilatory support, and prolonged ICU-stay. The postoperative CTA showed patent bypasses, aortic remodelling, and minimal type IIa endoleak at the level of the ALSA. The patient was discharged in good cardiovascular and neurological condition after 3 weeks with a well-controlled blood pressure. Her medication consisted of olmesartan 40 mg q.d., amlodipine 5 mg b.i.d., bisoprolol 10 mg q.d,, atorvastatin 40 mg q.d., and 80 mg of aspirin q.d. Smoking cessation was strongly encouraged. At 1- and 3-month follow-up, the patient had quit smoking and was still fatigued but in good shape. Clinical examination showed normal wound healing, bilateral normal brachial and femoral pulses, and good blood pressure control. At 3 months follow-up, a follow-up CTA showed a good position of the stent-graft, patent carotid-subclavian bypasses, a diminished type IIa endoleak, and a decrease in size of the false lumen and the KD ().