Serial false lumen patency evaluation of a type B dissection represented with malperfusion following medical management

False lumen evolution in type B aortic dissection, particularly with medical management and anticoagulation, remains incompletely understood. We report a 55-year-old man on apixaban for pulmonary embolism with a subacute zone 3-10L TBAD without malperfusion. He was managed medically initially and represented twice over 2 months with back pain and acute right lower extremity ischemia. Serial imaging demonstrated dynamic remodeling with progression from partial to near-complete thrombosis to full reperfusion with true lumen compression. Urgent endovascular repair was performed successfully. This case illustrates the unpredictable course of medically managed TBAD and need for judicious use of anticoagulation.