The management of patients with complicated acute type B aortic dissection is challenging. Thoracic endovascular aortic repair has shown promising results in small series; however, using nonstandard definitions and improper inclusion criteria confounds the published results. This article reviews the techniques and outcome of patients who underwent endovascular treatment for complicated acute type B aortic dissection in North America. Primary stent grafting for treatment of complicated acute type B aortic dissection compares favorably with the surgical outcome. Thoracic aortic endovascular repair can be offered with a relatively low postoperative morbidity and mortality in experienced hands. It also appears to have a favorable outcome in mid-term follow-up. Longevity of the repair and durability of the stent grafts in the thoracic aorta are yet to be established.