Type B acute aortic dissection is not uncommonly encountered by cardiovascular and thoracic surgeons. However, the optimal treatment of patients, particularly those with visceral and renal vessel ischemia, is not well standardized. This is, in part, because of the high morbidity and mortality that continues to plague aortic replacement surgery in that setting. For this reason, other techniques have been investigated. Surgical aortic fenestration and percutaneous balloon fenestration are two attractive alternative solutions to this serious problem. We describe both procedures, illustrating their relative ease of performance, and review the most recent data regarding outcomes. Open surgical aortic fenestration is a quick and safe alternative to traditional operative strategies and has been shown to have both short-term and long-term effectiveness. Percutaneous balloon fenestration, although a more recent technique, appears to offer the same advantages as open fenestration with the added benefits of a minimally invasive approach. We believe that these two techniques can be safe and effective alternatives to medical management and aortic replacement surgery in properly selected patients.