Background <p>Management of acute aortic dissection (AAD) caused by retrograde perfusion through the femoral artery during minimally invasive cardiac surgery (MICS) remains controversial. We present a case of AAD occurring during the late cardiopulmonary bypass (CPB) phase, which was successfully managed by vascular graft replacement, without altering the blood supply route.</p> Case presentation <p>A 63-year-old man was scheduled for totally endoscopic aortic valve replacement. CPB was initiated through the right femoral artery and venous cannulation. Approximately 120&#xa0;min after the initiation of CPB, mean arterial pressure and bilateral cerebral regional oxygen saturation temporarily decreased. Transesophageal echocardiography revealed type A AAD. Cerebral perfusion was preserved, allowing us to proceed to deep hypothermic circulatory arrest and successfully perform ascending aortic replacement without altering the blood supply route.</p> Conclusions <p>In MICS, continuous monitoring is crucial as AAD can occur at any point during CPB, and early detection enables successful outcomes.</p>