This is a pediatric patient with smog who underwent combined bypass surgery with vascular bypass + multifactor patching. More than 1 year after surgery, the review imaging showed not only extensive formation of bypass vessels in the middle cerebral artery region and significant regression of the smog vessels, but also good formation of bypass vessels in the anterior cerebral artery region, which is crucial to the restoration of normal intelligence and emotion in the smog patient, an effect impossible to achieve with traditional surgical methods. This demonstrates that the new combined vascular bypass surgery is superior to the traditional surgical approach and is worth promoting. Although the vast majority of pediatric smog patients can form bypass vessels with simple patching surgery, the latter has a greater range of bypass vessel formation and better results compared with the new surgical method (vascular bypass + multifactor patching), especially the frontal ostium patching can improve blood supply to the frontal brain tissue, which has an important role in improving the intelligence of children. Figure 1 Preoperative right internal carotid artery angiogram Figure 2 Postoperative right internal carotid artery angiogram with good formation of frontal osteochondral patching and significant reduction of right smoky vessels Figure 3 Preoperative left internal carotid artery angiogram Figure 4 Postoperative external carotid artery angiogram with smooth bypass and good new bypass vessels with large scope to meet the need of blood supply to the brain Figure 5 Postoperative left internal carotid artery angiogram showing that left smoky vessels also largely disappeared