Background and Aims: The treatment of aortic arch lesions is a difficult problem to be solved in clinical practice. The technology of complete endovascular repair is the important research direction of this condition. Because of the diversity and complexity of the local anatomical morphology of aortic arch lesions, reconstruction of the supra-arch vessels with effective cerebral circulatory protection is still a major challenge. This study was conducted to investigate the efficacy and safety of the application of selective establishment of individualized extracorporeal circulation mode combined with technique of in-situ needle fenestration in endovascular repair of aortic arch lesions, so as to provide certain reference and new research strategies for the treatment of this condition.  
Methods: The clinical data of 8 patients with aortic lesions involving the arch (3 cases of Stanford type A aortic dissection, 3 cases of aortic arch aneurysm, and 2 cases of aortic arch penetrating ulcer) treated from January 2018 to June 2019 were retrospectively analyzed. According to the preoperative transcranial Doppler ultrasound (the anterior and posterior cerebral communicating arteries and arterial circle of Willis as well as the dominance of bilateral vertebral arteries), the selective application of right femoral vein-right axillary artery and left common carotid artery with (or without) left axillary artery diversion mode was determined to establish the individualized extra-cardiopulmonary bypass for intraoperative cerebral protection. According to the basic cerebral blood flow chart, the flow and pressure of extracorporeal circulation were reasonably and accurately controlled. After the release of the thoracic aortic covered stent, the supra-arch branches were reconstructed by endovascular in-situ needle fenestration followed by balloon dilation of the hole and then Viabahn covered stent insertion. CTA of the aorta was performed 3, 6, 12 and 24 months after operation for follow-up.
Results: Operations were successfully performed in all patients, and no surgical death occurred. The total of 14 Gore TAG thoracic aortic covered stents and 19 Gore Viabahn covered stents were implanted. Three branches were fenestrated in 3 cases and two branches were fenestrated in 5 cases during operation. In the whole group of patients, the operative time was 180–360 min, with an average of (240±30) min, the time for fenestration was 18–55 min, with an average of (35±5) min, and the intraoperative blood loss was 300–800 mL, with an average of (400±50) mL. The length of postoperative ICU stay was 2–5 d, with an average of 2.5 d. Mild lacunar cerebral infarction occurred in one case after surgery, and was recovered after symptomatic treatment with anticoagulation and improvement of cerebral circulation. All the 8 patients were discharged from hospital 5–10 d after operation. The follow-up period was 6–24 months. CTA showed that the aneurysmal sacs and tears of dissection and ulcers were satisfactorily occluded, and thrombus organization and remodeling were seen in the aneurysmal sacs and false lumens. 
Conclusion: Individualized extracorporeal circulation mode combined with in-situ needle fenestration and branch reconstruction is a feasible, effective and safe as well as minimally invasive method for the treatment of aortic arch lesions, with the advantages of definite brain protection, accurate and rapid fenestration, fast postoperative recovery and fewer complications. Its short-term efficacy is excellent and long-term efficacy needs to be clarified by further followed-up observations.