Asian Cardiovasc Thorac Ann 2008;16:346-347
© 2008 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Left Upper Limb Shortening Following Reverse Flap Subclavian Artery Angioplasty
Madan M Maddali, MD,
Raj G Menon, McH,
John Valliattu, FRCS,
Hilal A Maimouna, MBChB
Departments of Anesthesia and Cardiothoracic surgery, Royal Hospital, Muscat, Oman
For reprint information contact: Madan M Maddali, MD Tel: 968 590 192 Fax: 968 590 192 Email: madan{at}omantel.net.om Department of Anesthesia, Royal Hospital, PB No. 1331, PC: 111, Seeb, Muscat, Sultanate of Oman.
A 9-year-old boy who had undergone reverse subclavian flap angioplasty for repair of aortic coarctation at 12 days of age, presented with recurrent coarctation and stunted left upper limb (Figure 1
). The length from the tip of right acromial processes to the styloid process of the radius was 41 cm, and in the left arm it was 39 cm. The length from the acromial processes to the tip of the index finger in the right upper limb was 55 cm, and in the left upper limb it was 53 cm. Peripheral pulses in the left arm were weak. Noninvasive blood pressure recordings were (mm Hg): right upper limb, 130/60; left upper limb, 70/60; right lower limb, 75/50; left lower limb, 78/54. Catheterization revealed a tight coarctation (Figures 2 and 3) with an 80 mm Hg systolic pressure gradient. At reoperation, initial pressures in the right radial and left dorsalis pedis artery were 130/70(91) and 66/53(58) mm Hg, respectively (mean gradient, 33 mm Hg). Immediately after anastomosis of a 14-mm graft across the coarctation, pressure readings were (mm Hg): right radial artery, 115/57(77); dorsalis pedis artery, 74/52(60); mean gradient, 17. Recordings at discharge were (mm Hg): right upper limb, 120/66; left upper limb, 116/70; right lower limb 120/60; left lower limb 132/63.
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Figure 2. Pulmonary artery angiogram in shallow left anterior oblique view (laevo phase) shows filling of ascending aorta and arch; the ascending aorta is dilated, with normal brachiocephalic and carotid arteries; the subclavian artery is turned down and connected to the descending aorta.
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Figure 3. Descending thoracic aortogram in lateral view shows dense filling of descending aorta with a blind upper end. The subclavian artery fills retrogradely from the descending aorta towards the proximal arch. Non-contrast flow is seen from the proximal aorta into the descending aorta through the subclavian artery.
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