The traditional surgical strategy for type B aortic coarctation isolation involving the aortic arch is to replace the distal aortic arch and descending aorta, which often requires deep hypothermic arrest of circulation or femoral arteriovenous diversion, which is a complex procedure and causes certain complications [1]. In recent years, intra-aortic luminal isolation technique is widely used to separate type B aortic coarctation [1,2], and the rate of surgical mortality complications is significantly reduced compared to conventional surgery. The hybrid technique (hybrid), which combines branch vessel bypass surgery on the aortic arch with endoluminal treatment of the aorta [3,4], has opened up a simple, safe and effective new method for the treatment of type B coarctation involving the aortic arch. In this paper, we summarize the experience of our department in performing hybrid surgery for type B coarctation involving the aortic arch in the past year and the results of short-term follow-up. 1.Data and methods Our department admitted 10 cases of type B acute aortic coarctation separated from December 2009 to September 2010, among which 3 cases involved the aortic arch. Two cases involved the Z3 region near the root of the left subclavian artery and one case involved the Z2 region (see Figure 1). two cases had previous hypertension for many years and one case had chronic renal insufficiency and renal hypertension for many years and was treated with intermittent abdominal dialysis before admission. three patients were diagnosed with acute aortic dissection type B by aortic CTA examination after admission. All three patients underwent cerebrovascular CTA, suggesting good traffic in willis loop and left and right basilar arteries. Figure 1: Zones of the aortic arch: Z0 includes the ascending aorta to the distal end of the opening of the unnamed artery, Z1 includes the distal end of the opening of the unnamed artery to the distal end of the opening of the left common carotid artery, Z2 includes the distal end of the opening of the left common carotid artery to the distal end of the opening of the left subclavian artery, Z3 includes the descending aorta 2 cm distal to the opening of the left subclavian artery, and Z4 includes the descending aorta below 2 cm distal to the opening of the left subclavian artery. All patients underwent staged hybridization after perfecting preoperative preparation. In the first stage, cephalobrachial trunk bypass surgery was performed: the surgery was performed under general anesthesia and cerebral oximetry monitoring. In two of the procedures, the left common carotid artery (LCCA) and the left subclavian artery (LSA) were bypassed by making small incisions in the left medial sternocleidomastoid muscle and the left subclavian, respectively, to expose the LCCA and LSA, and the LSA was clamped by the lateral wall, incised longitudinally, and an 8-mm artificial vessel was placed with a 5-0 polypropylene suture ( Hemashiled, Boston Scientific Co., USA) to the LSA, then the other end of the artificial vessel was traversed behind the clavicle to the left neck, and the artificial vessel was anastomosed to the LCCA in the same way behind the sternocleidomastoid muscle. Cerebral oximetry (INVOS cerebral oximeter 5100B, Smanetic Corporation, USA) was monitored during the whole procedure and there was no significant change. The Hercules straight tubular overlapping stent (Shanghai Minimally Invasive Medical Devices Co., Ltd.) 30-34 X 160 mm was used for the endoluminal repair under DSA guidance, and intraoperative selective bridge angiography and CTA showed that the LSA to LCCA bridge was patent, and the proximal anchor point was located below the LSA. The stent was opened and completely covered the LSA opening (see Figure 2B). In the other case, the ascending aorta, LSA and LCCA were bypassed: the sternum was transected at the second intercostal space, the right internal mammary artery was preserved, the left internal mammary artery was cut and sutured, the thymus gland and the innominate vein were separated, the ascending aorta, innominate artery, LSA and LCCA were fully exposed, the LSA was clamped at the lateral wall, the 8mm artificial vessel was anastomosed to the end of the LSA with a 5-0 polypropylene suture, and the other 8mm artificial vessel was anastomosed to the end of the LCCA in the same way. The ascending aorta was partially blocked by the lateral wall clamp, and the proximal ends of the two artificial vessels were anastomosed to the wall of the ascending aorta with 4-0 polypropylene sutures. Intraoperative cerebral oximetry monitoring did not show any significant changes throughout the operation. Intraoperative ascending aortic angiography showed that the bridge vessel was patent, the proximal anchorage point was located at the junction of Z1 and Z2, the anterior bare stent had reached the Z0 area, and the peritoneal part of the stent completely covered the LSA and partially covered the LCCA (see Figure 3). 2. Results All cases recovered well after surgery with a hospital stay of 17 days (12 to 25). In the early follow-up, CTA review was performed only six months after surgery in one case because of chronic renal insufficiency before surgery and consideration of the toxic side effects of iodine contrast agent on the kidney, and aortic CTA review was performed in the remaining two cases at 1, 3, 6, and 9 months after surgery, respectively, whose results showed that none of the intraluminal stents were displaced and no endoleaks occurred. two patients had bypass bridge vessels located in the neck, and the peak flow velocity of the bridge vessels was monitored by vascular Doppler ( In one case, numbness of the left upper extremity occurred after the second-stage surgery, which did not exclude the possibility of brachial plexus nerve injury, and the symptoms were relieved after 2 weeks of treatment with methylcobalamin and furathiamine. Bavaria et al. reported that the mortality rate of TEVAR is 2% and the postoperative complication rate is 3%, while the mortality rate of conventional surgical treatment is 3%. compared to 11% mortality and 15% postoperative complication rate for conventional surgical treatment, suggesting that TEVAR is safer and more effective in the treatment of type B aortic coarctation [1]. However, the rupture of type B coarctation is mostly located at the beginning of the descending aorta, often involving the aortic arch, and the inadequate length of the proximal anchorage zone (P LZ) in this case directly leads to a high incidence of leakage within the stent attachment zone (type I endoleak), which is the main cause of aneurysm rupture after endoluminal treatment [5], whereas supra-arch vascular bypass can expand the proximal anchorage and reduce the possibility [6]. There are various types of arch vascular bypasses available, but they have a single purpose, i.e., to expand the proximal anchorage and reduce the complications of TEVAR. The optimal length of the anchorage zone is still controversial, but most current studies suggest that it is above 1-2 cm [7,8], and after treatment with supra-arch vascular bypass, the anchorage zone is increased by at least 2 cm from the original one. the choice of the proximal anchorage site determines the mode of supra-arch branch vascular bypass of the aorta, which only needs to cover the Z2 or Z3 zone of aortic entrapment, only the left common carotid artery or ascending aorta to the left clavicular The approach is also called supra-aortic debranching (supra-aortic debranching) [9,10,11], as shown in Figure 4. The easiest way to access the supra-aortic vessels for bypass surgery is to make an incision in the neck to complete the procedure. This avoids opening the chest and reduces the occurrence of thoracic complications on the one hand, and reduces bleeding and recovery time on the other. It has even been reported that bypass surgery of the right and left common carotid arteries was completed under local anesthesia [12]. In addition to cervical incision, median sternotomy as well as transverse sternotomy and L-shaped left hemithoracotomy can also expose the aortic arch well, especially when more than two branches of the arch need to be bypassed, which can reduce the injury of peripheral neurovascular. [13,14,15] Whether left subclavian artery (LSA) [ZQ1] closure causes upper extremity ischemia, cerebrovascular accidents, and spinal cord ischemia in patients is controversial.Rizvi AZ et al. concluded from a meta-analysis of 51 studies that the likelihood that LSA closure may cause these complications is low [16].Kotelis D et al. concluded from a retrospective analysis that selective performance of LSA bypass can reduce the above complications, and the selection indications are: a, left hand dominant, b, left vertebral artery dominant type, c, right vertebral artery dysplasia or acquired caused stenosis or even obstruction, d, left mammary artery dominant, e, patients with permanent arteriovenous fistula in the left upper limb artery (hemodialysis patients) are all strong indications for performing left subclavian-left common carotid artery bypass strong indication for left subclavian-left common carotid artery bypass [17]. The American College of Vascular Surgeons guidelines recommend preoperative bypass if the patient requires LSA closure for TEVAR, despite the absence of strong evidence-based evidence (GRADE 2, level C) [18]. In our group, all three patients underwent left subclavian artery bypass. The hybridization technique for the treatment of type B entrapment involving the aortic arch requires partial or complete blockage of the cephalobrachial trunk, and the willis loop has a high variability rate of 50% [19]; therefore, preoperative cerebrovascular CTA should be performed to clarify that the left and right cerebrovascular collateral circulation is good and to avoid intraoperative cerebral hypoxia causing perioperative cerebrovascular accidents and hemiparesis that have not occurred. Many clinical reports have confirmed that intraoperative close monitoring of cerebral oxygen using near-infrared cerebral oximetry (NIRS) can reduce the occurrence of stroke and ischemic encephalopathy in cardiovascular surgery, especially in macrovascular surgery [20,21,22]. If intraoperative cerebral hypoxia occurs, an intraluminal shunt should be placed [23] to prevent cerebral ischemia. With these measures, the neurological complications of hybridization surgery are much lower than those of traditional “elephant trunk surgery” [24]. 4. Conclusion The hybridization technique is a simple, safe, and effective new method for the treatment of type B aortic coarctation involving the aortic arch. The diversion of the vessels in the arch depends on the extent of the anchored area, and further studies are needed to optimize the diversion and surgical access, and further follow-up is needed for long-term results.