Aortic malperfusion occurs in a significant percentage of patients with acute aortic dissection, and causes malperfusion syndrome, the clinical entity defined by end organ ischemia, in 10–33% of patients. Malperfusion syndrome can be rapidly lethal and can involve the coronary, cerebral, visceral, or lower extremity vessels. Depending on presentation, it may be appropriately and well treated with endovascular fenestration prior to definitive central aortic repair.