Aortic arch obstruction is often combined with complex intracardiac malformations such as ventricular septal defect, left ventricular outflow tract stenosis, right ventricular double outlet (Taussig-Bing type), complete atrial septal defect, and complete transposition of the great arteries, which require simultaneous correction. Aortic constriction, aortic arch dysplasia and aortic arch disruption are the three most common manifestations of aortic arch obstruction. At present, one-stage aortic arch angioplasty and correction of intracardiac malformations through a median sternotomy is still a major surgical challenge. This article summarizes our experience with one-stage aortic arch plication. Data and methods 1. Clinical data: 24 cases were treated surgically from January 2007 to July 2008. The ages ranged from 1 to 99 months, with a mean of 16 months. There were 18 cases of infants, 1 case of toddlers and 5 cases of children. Body weight ranged from 4 to 19 kg, with an average of 9.3 kg. All were clearly diagnosed preoperatively by echocardiography and 64-row spiral CT. Aortic arch obstruction included aortic constriction in 9 cases, aortic constriction combined with aortic arch dysplasia in 12 cases, and aortic arch interruption in 3 cases. The total combination with right ventricular double outlet (Taussig-Bing type) was found in 4 cases, subaortic stenosis in 1 case, and pulmonary vein stenosis in 1 case. 22 of 24 patients were combined with non-restrictive ventricular septal defect, and 2 were not. In all patients, aortic arch angioplasty and correction of intracardiac malformation were performed in one stage using a median sternotomy. Three patients with interrupted aortic arch and nine patients with aortic narrowing were treated with end-to-end anastomosis. 8 of 12 patients with aortic arch dysplasia were treated with expanded end-to-end anastomosis, 2 with end-to-side anastomosis, and 2 with patching. 2. Surgical method: Conventional median sternal incision was made and thymic tissue was completely removed. The aorta, ascending aorta, aortic arch and its branches were fully freed, and the left and right pulmonary arteries were freed to the bifurcation and set aside with rubber bands. Simple ascending aortic cannulation (arterial cannula: Medtronic DLP 77010, Medtronic Inc. Minneapolis, MN 55432-5604, USA) was used except for patients with interrupted aortic arch who required dual arterial cannulation via the ascending aorta and pulmonary artery-arterial catheter-descending aorta. The arterial catheter was cut and sutured during hypothermia, and the descending aorta was fully freed to the second or third intercostal artery, taking care to protect the vagus nerve and branches. The nasopharyngeal temperature was reduced to 25 ml/kg/min at 18oC and the mean radial artery pressure was maintained at 30-40 mm Hg. The ascending aortic cannula was adjusted to the innominate artery and ligated for blockage, the left common carotid artery and the left subclavian artery were blocked with a silver clip to close the rubber band, and the descending aorta was clamped with a blocking forceps (the descending aortic cannula was removed at the same time in patients with interrupted aortic arch). The catheter tissue is adequately removed and aortic archplasty is performed using different methods depending on the development of the aortic arch. After surgery, the aortic cannula was repositioned to the ascending aorta, flow was restored, rewarming was performed and intracardiac malformation was corrected. One patient with Taussig-Bing malformation combined with aortic constriction and arch dysplasia died of severe infection 47 days after aortic arch angioplasty, arterial reversal and septal defect repair; the other patient with interrupted aortic arch died of pulmonary hypertension crisis 15 days after surgery. There were no neurological complications or renal impairment during the perioperative period in the whole group of patients. There were two cases of recurrent postoperative respiratory tract infections. Except for one case with a residual pressure difference greater than 20 mmHg, the longest follow-up of 18 months has not revealed the occurrence of recanalization. Discussion The aortic arch consists of three parts: the proximal arch (between the innominate artery and the left common carotid artery), the distal arch (between the left common carotid artery and the left subclavian artery), and the isthmus (between the left subclavian artery and the ductus arteriosus). Aortic arch hypoplasia (aortic arch hypoplasia) is defined as the proximal arch, distal arch, and isthmus being less than 60%, 50%, and 40% of the diameter of the ascending aorta, respectively. Some scholars also use a transverse arch diameter of less than mm/kg+1 or a Z value of less than -2 as criteria. There are three types of aortic arch hypoplasia: Type I: distal aortic arch hypoplasia, i.e., distal arch and isthmus hypoplasia; Type II: complete aortic arch hypoplasia, i.e., complete arch hypoplasia (tubular stenosis); Type III: complex aortic arch In this group of 12 patients with aortic arch hypoplasia, there were 8 cases of type I, 3 cases of type II, and 1 case of type III. For aortic constriction combined with non-restrictive ventricular septal defect, there are three surgical strategies: complete single-stage repair, committed two-stage repair and uncommitted two-stage repair. repair). In the past, the latter two options were mostly used. The non-committed two-stage surgery is the classical two-stage surgery, in which the aortic constriction is first corrected through a left posterior lateral thoracic incision, with or without pulmonary artery circumferential reduction. Ventricular defect repair is then usually performed several months later through a median sternotomy. The disadvantages are: (i) the need for two operations and two incisions; (ii) the risk of pulmonary artery annuloplasty: distortion of the pulmonary artery branches or deformation of the pulmonary valve due to the low position of the fascia and the possible need to tighten or loosen the unsuitable fascia again; and (iii) the difficulty of correcting the postero-lateral incision in the presence of proximal arch dysplasia. The one-stage two-incision procedure, also known as one-stage two incision, is performed under a single anesthetic to correct aortic stenosis through a posterior lateral incision in the left thorax, followed by a median sternal incision to repair the ventricular defect. Again, two incisions are required and do not provide a good solution to the problem of proximal arch dysplasia. With the improvement of surgical techniques and extracorporeal circulation, more and more centers are preferring a complete one-stage procedure. The advantages are: (i) the possibility of resolving all cardiac malformations at once; (ii) the immediate restoration of normal anatomy and physiology; (iii) the definitive relief of transverse arch dysplasia; (iv) the avoidance of the corresponding complications associated with pulmonary artery annuloplasty; and (v) the avoidance of heart failure that may occur during both procedures and require emergency management. Therefore, for patients with aortic arch obstruction combined with complex intracardiac malformations, we prefer complete one-stage surgery. The methods of aortic arch angioplasty include end-to-end anastomosis, expanded end-to-end anastomosis, end-to-side anastomosis, patch angioplasty, and vascular graft implantation. Our experience is that: ①, paracatheter or postcatheter aortic constriction is often more limited and is usually not combined with aortic arch dysplasia. As with aortic arch disruption, good results can be achieved with end-to-end anastomosis after excision of the ductal tissue. For type I arch dysplasia, an expanded end-to-end anastomosis can be performed by completely removing the ductus arteriosus and isthmus and then anastomosing the descending aorta between the left common carotid artery and the left subclavian artery; for type II and III arch dysplasia, an end-to-side anastomosis can be performed by anastomosing the descending aorta between the innominate artery and the left common carotid artery, leaving the distal arch open. between the innominate artery and the left common carotid artery, leaving the distal arch and isthmus open. (iii) The tissue-tissue anastomosis technique is used as much as possible, and patchplasty is avoided. This is because whatever the material (artificial material, homograft, fresh or glutaraldehyde-fixed autologous pericardium) can lead to distant unmanageable pseudoaneurysms with a high incidence of restenosis. Although some authors have suggested that the risk of pseudoaneurysm and restenosis can be reduced by applying autologous pulmonary artery patching (the anterior wall of the main pulmonary artery is used as patch material and the defect is repaired with autologous pericardium), it has a short follow-up time and no material is available in case of distant secondary left ventricular outflow tract stenosis requiring Ross-Konno surgery. ④, Extended end-to-end and end-to-side anastomosis techniques are more suitable for patients younger than 2 years of age, especially in small infants. Generally, the anastomosis can be completed successfully at a distance of no more than 2.5 cm. The older the patient is, the worse the vascular free degree and the greater the tension of the anastomosis, the more likely it is to cause surgical failure or restenosis. In our group, seven of the eight patients with type I arch dysplasia underwent expanded end-to-end anastomosis, and one patient aged 8.5 years had a large tension despite complete release of the vessel, which was eventually converted to patchplasty. In the other three patients with type II and one patient with type III dysplasia, two patients with type II dysplasia underwent end-lateral anastomosis; the other patient underwent expanded end-lateral anastomosis, but mild stenosis remained in this patient after surgery. one patient with type III dysplasia could not undergo end-lateral anastomosis successfully because the stenotic segment was too long, so patching was performed instead. 2.Extracorporeal circulation technique In 1996, Asou et al. first proposed the method of continuous selective cerebral perfusion, which greatly reduced the neurological complications associated with the previous application of deep hypothermic stopping circulation. Because of the good protective effect on the brain and myocardium, it has now become a technique routinely applied in aortic arch angioplasty. However, there are still major debates about the optimal flow rate, temperature, safety time frame and blood gas management. Our currently applied protocol is: nasopharyngeal temperature of 18oC, flow rate of 25ml/kg/min, maintenance of mean radial artery pressure of 30~40mmHg, erythrocyte pressure product (Hct) of 25~30%, and venous oxygen saturation of >70%. The average low-flow time for the whole group of patients under this protocol was 25 minutes (18-34 minutes), and no neurological complications or renal impairment occurred. Residual stenosis or recurrent narrowing Residual stenosis or recurrent narrowing is defined as a pressure difference of more than 20 mm Hg across the aortic arch repair area at rest, which may be caused by inadequate excision of the arterial catheter tissue, high local anastomotic tension, or the reappearance of the narrowing ridge with the application of a patch or left subclavian angioplasty. Some authors have also suggested that restenosis is related to a poorly developed morphology of the aortic arch, such as failure of the proximal aortic arch to grow and develop after repair of tubular stenosis. We appreciate that the cause of restenosis may be related to the free release of the vessel and inadequate excision of the arterial conduit tissue as well as the inappropriate choice of procedure. In one of our patients, the residual stenosis was due to an enlarged end-to-end anastomosis of the proximal arch instead of an end-to-side anastomosis of the aortic arch. Therefore, in order to prevent the occurrence of re-stenosis, it is recommended that: (1) the thoracic vessels be extensively and thoroughly freed and released so that the anastomosis is performed in a tension-free state; (2) the arterial conduit tissue and the aortic isthmus be completely excised; (3) the appropriate procedure be chosen so that the anastomosis extends beyond the most proximal stenosis; and (4) tissue-tissue anastomosis be performed as much as possible without the use of patch-forming methods. Balloon dilation or stenting is preferred for the correction of re-stenosis. For patients who are not suitable for interventional treatment or for whom interventional treatment is not effective, autologous pulmonary artery patching can be used if the residual aortic arch stenosis is relatively limited, or “gliding technique” can be applied to re-form a longer segment of dysplastic aortic arch if it is more elastic. Only if the above methods cannot be solved, the artificial vessel diversion technique will be applied. 4, airway compression The normal aortic arch is a circular curve, so that the large vessels such as the main and pulmonary arteries have enough space with the trachea and bronchi without forming airway compression. After aortoplasty, especially after end-lateral anastomosis, the distance between the descending aorta and ascending aorta is shortened, so that the normal circular curve of the aortic arch disappears and the ascending and descending aorta are connected at an acute angle, which compresses the space between it and the airway and produces airway compression symptoms, resulting in prolonged ventilator assist time and recurrent airway symptoms. The recurrent postoperative airway spasm and pulmonary infection in our two patients may be related to airway compression. Thorough free release of the descending aorta, aortic arch and branches, and left pulmonary artery, so that the anastomosis is performed in a tension-free state, often prevents the occurrence of airway compression. Conclusion The application of a continuous selective cerebral perfusion approach to perform aortic arch plication in one stage through a median sternotomy is safe and effective. Adequate excision of the ductus arteriosus, extensive and thorough freeing and release of the thoracic vessels, and selection of an appropriate tissue-tissue anastomosis are the keys to successful aortic arch angioplasty and reduction of recanalization.