I. Overview Pulmonary artery sling is a rare and serious congenital disease that endangers the health of infants and children, often in combination with tracheal stenosis. The severity of the disease is graded: children with persistent dyspnea are generally defined as moderate, and respiratory failure on top of dyspnea is considered severe. Pulmonary artery sling is an abnormal origin of the left pulmonary artery from the right pulmonary artery and travels backward to the left via the posterior tracheal bifurcation, anterior to the esophagus, and finally to the left hilum. For more than half a century, the prognosis for infants and children with pulmonary artery sling has been unsatisfactory. At present, clinical management of children presenting with moderate to severe pulmonary artery sling is usually performed via median sternotomy stage I surgery to correct vascular malformations (left pulmonary artery graft) and tracheal stenosis (tracheoplasty), but postoperative airway complications, such as poor anastomotic healing in the early postoperative period resulting in mediastinal emphysema, late anastomotic granulation tissue formation, and leading to reanastomotic stenosis, etc. In order to avoid intractable post-tracheoplasty complications, for children with moderate to severe pulmonary artery sling, our unit adopts a protocol of left pulmonary artery grafting under non-extracorporeal circulation, early postoperative extubation and CPAP transition. II. Treatment of pulmonary artery sling 1. Treatment of mild pulmonary artery sling The natural incidence of pulmonary artery sling is low. The degree of criticality and treatment strategy of children with pulmonary artery sling depends on the severity of tracheal stenosis and intracardiac malformation. ventilator assistance). Bronchoscopy in children with mild pulmonary artery slings reveals limited tracheal stenosis with a diameter of 4 mm or more (in infants under 6 months of age), while endoscopy in children with moderate to severe pulmonary artery slings reveals tracheal stenosis less than 4 mm in diameter, complete tracheal cartilage rings and lesions often involving the rongeurs and bronchi. Clinical symptomatology staging is primarily a guide to the choice of clinical surgical approach. Given the risks of surgical treatment for children with pulmonary artery slings, most medical units recommend conservative treatment for children with mildly symptomatic pulmonary artery slings, while some institutions and physicians perform pulmonary artery transplantation in children with such mild pulmonary artery slings because children with mild symptomatic staging can become medium or even severe at any time, with extremely severe respiratory distress symptoms. In our unit, all children with pulmonary artery slings were above moderate to severe, and two cases were even admitted to the care unit with respiratory failure and were mechanically ventilated by tracheal intubation. 2.Medium-severe pulmonary artery sling treatment Most of the children with pulmonary artery sling are seen for dyspnea, with moderate to severe respiratory symptoms, or even respiratory failure, requiring mechanical assisted ventilation, and there is a big controversy in the treatment plan for such children. Most institutions and physicians recommend simultaneous correction of vascular malformations and tracheal stenosis malformations in phase I under extracorporeal circulation via a median sternotomy. The advantage of the simultaneous correction of cardiovascular malformations and tracheal stenosis approach is that it can solve the problem in one go, and as long as tracheoplasty is satisfactory, adequate ventilation can be ensured in the early postoperative period with low pressure on airway management. However, the disadvantages of this method are also obvious, firstly, the high postoperative mortality rate in children under 1 year of age, because correction of tracheal malformation and cardiovascular malformation may require a long extracorporeal circulation assistance time, and for infants under 1 year of age or even newborns, the tolerance ability to extracorporeal circulation is low, and the incidence of severe postoperative hypocapnia syndrome is high. air leak at the site, resulting in mediastinal emphysema, and late granulation tissue formation at the anastomosis, resulting in re-stenosis of the trachea, especially the formation of granulation tissue. Currently, Tsugawa et al. suggest that for children under 6 months of age with moderate to severe respiratory symptoms, a medical approach (e.g., tracheal balloon dilation) is generally used to delay the surgery as much as possible and allow further tracheal growth in order to obtain a higher success rate. However, even if the child is able to wait until he or she is over 1 year old to undergo tracheoplasty, the results are still not fully satisfactory. There are currently three main types of tracheoplasty procedures: simple stenosis resection with end-to-end anastomosis for short stenoses and autologous free tracheal piece tracheoplasty and slide tracheoplasty for long stenoses. Although slide tracheoplasty may have fewer postoperative complications than the other two procedures, some post-tracheoplasty-related complications cannot be avoided. The main complications are early tracheal anastomotic fistula and late tracheal softening and restenosis (due to anastomotic granulation). In Oshima et al. 11 patients who survived slide tracheoplasty with airway lesions involving the ridge had postoperative distal tracheal softening and anastomotic granulation in 7 cases, requiring tracheotomy. In children with pulmonary artery slings presenting with moderate to severe respiratory symptoms combined with tracheal stenosis, complications such as postoperative tracheal anastomosis granulation tissue formation and air leak remain a headache for clinical workers regardless of the type of tracheoplasty procedure, and there is no particularly effective treatment, and the prognosis is unsatisfactory regardless of tracheal stent placement or reoperation. This is also the reason why our unit advocates avoiding airway angioplasty as much as possible when dealing with children with combined tracheal stenosis and pulmonary artery sling. Considering the complications after tracheoplasty in children with moderate to severe pulmonary artery sling, can we avoid tracheoplasty and simply graft the deformed left pulmonary artery to relieve the compression of the trachea, so that the trachea can have room to grow and a better prognosis? For the following two reasons, we attempted a simple left pulmonary artery graft. Firstly, left pulmonary artery grafting is a mature and feasible procedure. At present, the treatment of malformed left pulmonary artery in children with pulmonary artery sling is mostly performed by left pulmonary artery grafting under non-extracorporeal circulation, and the results are also satisfactory. Secondly, after left pulmonary artery grafting, the tracheal compression is released, the trachea may have a period of accelerated growth, and the symptoms of tracheal stenosis can be improved. After left pulmonary artery transplantation alone, it is recommended to try to remove the tracheal intubation as early as possible. The experience of our unit is to withdraw the tracheal intubation as soon as the child resumes spontaneous breathing after postoperative anesthesia wakefulness, which has the advantage of mainly avoiding local tracheal mucosal edema and aggravation of tracheal stenosis due to contact friction between the tracheal intubation and tracheal stenosis. Clinically, in order to achieve early and successful withdrawal of the ventilator, we have taken the following two measures: firstly, to use non-invasive CPAP transition after withdrawal of the ventilator to reduce respiratory work; secondly, to avoid the use of extracorporeal circulation as much as possible during left pulmonary artery transplantation to reduce postoperative pulmonary exudation. III. Preliminary conclusions The number of cases in this study is small due to the extremely low natural incidence of pulmonary artery sling. We treated six children with combined tracheal stenosis and pulmonary artery sling since 2012 with simple left pulmonary artery grafting or severing of the ductus arteriosus ligament without tracheoplasty, and except for one case of death, the prognosis was good, with significant improvement or even disappearance of respiratory symptoms at follow-up without tracheoplasty. Children with pulmonary artery sling presenting with moderate-to-severe respiratory symptoms and combined with tracheal stenosis do not necessarily need tracheoplasty, and avoiding extracorporeal circulation as much as possible and using a strategy of rescue with simple left pulmonary artery graft, early postoperative extubation and noninvasive CPAP transition may result in a better prognosis.