Right aortic arch with DeBakey type III aortic coarctation is rare clinically, and only scattered cases have been reported in the literature, most of which are treated by traditional surgery. In February 2008, a patient with right aortic arch and vagal left subclavian artery with DeBakey III aortic coarctation was admitted to our hospital and was successfully treated with endoluminal repair, which is reported below. Data and methods 1. General data: The patient was a 65-year-old male with sudden onset chest pain for 5 days and aggravated for 8 hours when he was admitted to the emergency room on February 19, 2008. The patient was admitted to the local hospital 8 hours ago because of the sudden onset of severe chest tearing pain while riding a bicycle, and was transferred to our hospital because of aortic coarctation on CT examination. The patient had no dizziness or abdominal pain, no cold numbness in the extremities, no history of tracheoesophageal compression such as dysphagia, wheezing and recurrent pulmonary infections. History of hypertension for 5 years, irregularly treated with oral antihypertensive drugs. Physical examination on admission: T36℃ P76 times/min R19 times/min BP147/70mmHg was clear, carried to the ward, no pathological murmurs and vascular murmurs were heard in the heart and chest. Radial artery and dorsalis pedis artery (++). Auxiliary examination: routine blood WBC 12.00×109/L RBC 4.7×1012/L PLT 139×109/L, PT 12.2s, fibrinogen 8.5g/l, normal liver and kidney function, negative immunoscreening, EKG showed occasional premature ventricular beats, chest X-ray showed ascending aortic dilatation. On February 21, 2008, a CTA examination was performed after symptomatic treatment with antihypertensive and analgesic therapy, which revealed an aortic coarctation aneurysm (starting at the descending part of the aortic arch and ending 15 mm below the left renal artery), the right aortic arch and the thoracic aorta, and the branches of the aortic arch from the proximal to the distal end were the left common carotid artery, the right common carotid artery, the right subclavian artery and the vagus of the posterior esophagus. The thoracic descending aorta was located on the right side of the spine, the abdominal trunk, superior mesenteric artery, and right renal artery opened in the true lumen of the abdominal aorta, and the left renal artery rode across the true and false lumen of the abdominal aorta, and the maximum diameter of the descending aortic coarctation aneurysm was 92.2 mm, with a small amount of pleural fluid on both sides. 2. Treatment: The patient was admitted to the hospital and underwent aortography + endoluminal repair of aortic coarctation under intravenous complex anesthesia with tracheal intubation on March 3, 2008 after symptomatic treatment such as hypotension and analgesia. The aortic DSA angiogram was performed after confirming that the contrast was in the true lumen by hand pushing the contrast agent and the patient was seen to have congenital right aortic arch and vagal left subclavian artery and right thoracic aorta. The left subclavian artery opened in Kommerell’s diverticulum, the first rupture of the aorta was located in the thoracic aorta, 5 cm from the left subclavian artery, the right vertebral artery was the dominant artery, the diameter of the aneurysm was 9 cm, the diameter of the true lumen was 3 cm, the abdominal trunk, superior mesenteric artery and right renal artery opened in the true lumen of the abdominal aorta, the left renal artery rode across the abdominal The second breach of the aorta was located between the superior mesenteric artery and the renal artery (Figure 2). The “C” arm was locked at 45° in the left anterior oblique position to fully expand the aortic arch, and a 0.038″ Lunderquist superrigid guidewire was fed into the ascending aorta, through which a Hercules overmolded stent (HT4240-120-2000) from Shanghai Minimally Invasive Medical Devices Co. The left subclavian artery was not significantly visualized and other arteries were well visualized (Figure 3). 5-0 prolene non-invasive wire was used to close the right common femoral artery with continuous external suture. Intraoperative intravenous sodium heparin 40mg systemic heparinization, no intraoperative blood transfusion, operative time 2h. Results After the operation, the patient returned to the general ward and was given anti-infection, controlled hypotension and other treatments. The chest pain was gradually relieved, there was no dizziness, syncope, no necrosis of the left upper limb, no decrease in muscle strength of the limbs, no neurological complications, no dysphagia, respiratory wheezing and other discomforts. The patient was discharged from the hospital on March 17, 2008. CTA showed no enlargement of the aneurysm lumen and most of the thrombus formed in the false lumen with a small amount of type II endoleak (Figure 4). Discussion The incidence of right-sided aortic arch in the population is about 0.1%. There are 3 types of aortic arch based on the mode of branching, relationship to the esophagus, and congenital cardiac anomalies. Type 1 is mirror branching, accounting for 59% of cases. From the aortic arch, the left unnamed artery, right common carotid artery and right subclavian artery emanate sequentially. 75%-85% are associated with congenital heart diseases such as Follot’s tetralogy, pulmonary stenosis with ventricular septal defect, arterial trunk and tricuspid valve atresia. Type 2 with vagal left subclavian artery is present in 39.5% of cases. The aortic arch emanates sequentially from the left common carotid artery, the right common carotid artery, the right subclavian artery and the vagal left subclavian artery from Kommerell’s diverticulum located behind the esophagus. Most of these patients are usually asymptomatic or rarely symptomatic in adults. This is the case here. Type 3 is associated with an isolated left subclavian artery, which is connected to the pulmonary artery via an arterial conduit. This type accounts for 0.8% of cases, and 75-85% are associated with congenital heart disease. The first successful treatment of abdominal aortic aneurysm with stented prosthesis was performed by Parodi [9] et al. in 1991, and the first successful treatment of aortic coarctation and thoracic aortic aneurysm with endoluminal repair was reported by Dake [10] et al. in 1994 and has been widely performed worldwide since then. Endoluminal repair is becoming a well-established and preferred technique for the treatment of aortic coarctation and aortic aneurysms. Right aortic arch and vagal left subclavian artery with DeBakey type III aortic coarctation are extremely rare, with only about 10 cases reported in the foreign literature, all of which are treated with conventional surgery. Usually, it is a right-entry or left-entry thoracotomy or bilateral thoracotomy or sternal splitting thoracotomy under deep hypothermic stopping circulation, which is very traumatic, with high risk and high mortality. In recent years, two cases have been reported in the foreign literature about the successful experience of endoluminal repair for right aortic arch with thoracic aortic aneurysm, one case of left subclavian artery occlusion was directly performed endoluminal repair, and one case of left carotid artery to subclavian artery diversion and ligation of the proximal left subclavian artery before endoluminal repair, both of which were successful. However, there is only one case reported in China in which the right aortic arch and vagal left subclavian artery with DeBakey type III aortic coarctation were treated with endoluminal repair. In order to prevent basilar artery ischemia after blocking the bilateral subclavian arteries, the case was treated by first transposing the left subclavian artery to the left common carotid artery under cervical anesthesia and then performing endoluminal repair. In this patient we admitted, the first rupture of the aorta was 5 cm from the opening of the left subclavian artery, and the right vertebral artery was the dominant artery, and the vagus left subclavian artery opened at Kommerell’s diverticulum, so there was no problem with the anchorage area of the overlapping stent, and the problem of basilar artery ischemia was not likely to occur. According to foreign authors and our previous experience, as long as the left vertebral artery is not the dominant artery even if the left subclavian artery is blocked, necrosis of the left upper limb and subclavian artery steal syndrome will not occur. Therefore, in this case, we used intraluminal laminated stent implantation to seal the first breach of the aorta and block the left subclavian artery. Since the second breach was located between the superior mesenteric artery and the renal artery, if blocked, it might cause ischemia in the visceral artery, therefore, we took observation follow-up. After 8 months of follow-up, the patient had no dizziness or syncope, no necrosis of the left upper limb, no decrease in muscle strength of the four limbs, no neurological complications, and no discomfort such as dysphagia or respiratory wheezing. The key to endoluminal repair for right-positioned aortic arch and vagal left subclavian artery with DeBakey type III aortic coarctation is to properly treat the vagal left subclavian artery so that necrosis of the left upper extremity and subclavian artery steal syndrome can be avoided. If the left vertebral artery is the dominant artery, the left carotid artery can be diverted to the subclavian artery and the proximal left subclavian artery can be ligated before endoluminal repair, while if the left vertebral artery is not the dominant artery, it can be directly blocked. In conclusion, right aortic arch with aortic coarctation is rare, and traditional surgery is highly invasive and risky. We use an artificial vascular overlapping stent for endoluminal repair, which is less traumatic and has a faster recovery. Therefore, we believe that for patients with right aortic arch and vagal left subclavian artery with DeBakey type III aortic coarctation, good results can be achieved by endoluminal repair treatment, although careful preoperative examination and analysis are important guarantees for the success of endoluminal repair.