The primary goals of surgery for acute aortic dissection are to resect or control the intimal flap, prevent distal malperfusion, protect the brain and have a viable patient. However, several technical measures are important to prevent early and late sequalae, including adequate aortic resection, creating a stable anastamotic suture line, appropriate graft measurement and tailoring and completely resecting inciting aortic aneurysms. Utilizing simultaneous sternotomy and thoracotomy incisions, we report the re-operative management of a patient with an expanding distal aortic arch pseudoaneurysm, extending into the left pleural space, superimposed upon severely kinked proximal ascending aortic grafts and an aneurysmal aortic root only 6 months after initial repair.