Introduction: Background: This is a case of threatening right limb ischemia due to complicated acute type B aortic dissection was reperfused utilizing reversed petticoat technique to recanalize totally collapsed infra-renal true lumen. Case presentation: A male patient 55 years old known to be deaf-mutism presented to emergency department with acute onset chest pain persisting for 2 days that was diagnosed as unstable angina, clinical examination revealed blood pressure 195/130 mm. investigations was negative for unstable angina including ECG and cardiac enzyme. Patient was admitted for treating hypertensive crisis; 2 days later patient complained right lower limb severe pain with cold extremity and raised creatinine level. Vascular consultation was done and we provisionally diagnosed the patient as acute type B aortic dissection complicated with right limb malperfusion. CT angiography confirmed the diagnosis of type B aortic dissection with intimal tear 1cm distal to left subclavian artery; all visceral branches were perfused from true lumen except renal vessels were perfused from both true and false lumen. The infra-renal true lumen (TL) was totally collapsed causing right lower limb threatening ischemia and left lower limb was perfused through false lumen. Methods: after stabilization and control of blood pressure, we made our sizing plan and strategy based on preoperative CTA with three-dimensional multiplaner reconstruction. After detecting proximal and distal landing zones, under general anaesthesia patient underwent left carotid-left subclavian bypass. Reperfusion technique utilized dual vascular access, left brachial access (percutaneous) and right femoral access (cut down). After several trials to pass the wire through totally collapsed infra-renal true lumen, we utilized the dissection flap as a navigator to guide the wire into TL then to right common iliac artery. Reversed petticoat technique was utilized (the distal bare stent (Zenith dissection metal stent) was first placed into the compressed TL and deployed at the predetermined position allowing 50-55 mm for overlap with the proximal covered stent (Zenith thoracic alpha). Completion aortography was then performed to ensure coverage of the proximal entry tear and visualization of side branches, reperfusion of the right lower limb. Results: immediate technical success was proved by successful obliteration of the intimal tear with no Type I endoleak and successful reperfusion of right lower limb with adequately perfused visceral aortic branches. The patient had an uneventful recovery in the postoperative period and discharged 24 hours after the procedure. Conclusion: thinking outside the box utilizing nonstandard techniques may be helpful in solving technically challenging complicated cases. In our case, we employed reversed petticoat technique after navigation along the dissection flap to reperfuse totally collapsed infra-renal true lumen that resulting right lower limb threatening ischemia in acute type B aortic dissection with immediate technical success in sealing of intimal tear waiting for follow up to evaluate aortic remodeling.