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Type A aortic dissection (AAD) is a devastating complication of thoracic endovascular repair (TEVAR). In elderly patients, surgery for AAD carries considerable morbidity and mortality. Repair of AAD after previous TEVAR is an even greater challenge as it usually requires the arch to be addressed and a preexisting stent graft to be included into the aortic repair.A case series of 5 elderly patients who presented with acute AAD after previous TEVAR was reviewed. In 4 cases, there was retrograde AAD with involvement of the arch and stent graft. In 1 patient, intraoperative inspection showed no involvement of the arch. Three underwent ascending and subtotal arch replacement in moderate hypothermic circulatory arrest with selective cerebral perfusion. In 1 case, concomitant tricuspid valve repair was performed. The patient without involvement of the arch underwent emergent replacement of the ascending aorta in deep hypothermic circulatory arrest, and in the oldest, aged 88 years, surgery was limited to wrapping of the ascending aorta as an on-pump beating salvage procedure.Four (80%) of 5 patients survived and were discharged after an intensive care unit stay of 17.45 ± 15.98 days and a hospital stay of 26.0 ± 10.98 days. Mortality was 20%. All survivors were discharged with appropriate rehabilitation potential and without lasting neurological disabilities.