Acute aortic dissection is a total aortic catastrophe which must be managed emergently and preferably by experts in the field within expert centres who are able to manage the patients post operatively. The operating is challenging, even for the most experienced surgeon, and frequently in the night which adds to the difficulties. However, it can be immensely rewarding as a life can be saved and the natural history of such a severe pathology halted in its tracks. This chapter aims to help the reader navigate through the decision making processes involved from referral to discharge home and we hope you find it useful.