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Ann Thorac Surg 2000;69:1574-1576
© 2000 The Society of Thoracic Surgeons

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Case reports

Arm ischemia after subclavian flap angioplasty: repair by carotid-subclavian bypass

^a Department of Cardiothoracic Surgery, University of Southern California, Los Angeles, California, USA

Address reprint requests to Dr Wells, Division of Cardiothoracic Surgery, Childrens Hospital Los Angeles, 4650 Sunset Blvd, MS 66, Los Angeles, CA 90027
e-mail: wwells{at}chla.usc.edu

	Abstract

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Though quite unusual, vascular insufficiency of the arm can occur after ligation of the subclavian artery. We describe the ischemic consequences of left subclavian interruption in a neonate after subclavian flap angioplasty repair (Waldhausen procedure) for coarctation. Subsequent carotid-subclavian artery bypass was successful in relieving symptoms.

	Introduction

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Before modification of the Blalock-Taussig shunt operation, the subclavian artery was frequently ligated to create a direct systemic-to-pulmonary connection in cyanotic infants and children. In the more recent era, the usual indication for subclavian interruption has been subclavian flap angioplasty (SFA) for repair of coarctation. Though infrequent, there have been scattered reports [1, 2] of partial limb loss after subclavian ligation. In addition, several authors [3, 4] have documented abnormal growth, blood flow, and exercise tolerance in the arm after the procedure. Because symptomatic ischemia is so rare after sacrifice of the subclavian, virtually nothing has been written about upper extremity revascularization for this problem. We describe a 2-year-old boy with significant left upper extremity (LUE) vascular insufficiency after SFA for coarctation as a neonate. The successful management of this problem by carotid-subclavian artery bypass using a polytetrafluoroethylene (PTFE) graft and subsequent follow-up from that procedure are reported.

A 2-year-old boy was referred for LUE vascular insufficiency. As a newborn this child presented with critical coarctation and heart failure. He underwent SFA repair with an excellent result. The subclavian was ligated proximal to the branch vessels. During the first year of life the patient was noted to avoid use of the LUE, which he usually held close to his body. The left forearm and hand were cooler than the right and there were no palpable pulses. Reluctance to use the LUE progressed and at age 2 years a significant discrepancy in biceps and forearm circumference was noted. There was no history of light-headedness or syncope. An aortogram showed no gradient across the coarctation repair, and there was late filling in the distal left subclavian from the left vertebral. Subsequently, a left common carotid-subclavian bypass was done through a left supraclavicular incision. Despite maximal mobilization of the carotid and subclavian a primary anastomosis was not possible, so a supraclavicular interposition graft (6 mm PTFE) was used. Normal brachial, radial, and ulnar pulses were palpable after the procedure. The patient was discharged on aspirin.

Follow-up to 30 months has shown a return to normal function of the left arm. Pressures are equal in both upper extremities. There is minimal (< 1 cm) arm length discrepancy, and the circumferences of the upper arm and forearm on the left are 9% and 6% less than the right. These differences may result from right handedness. Doppler vascular study done 2 years after repair shows graft patency with brisk flow and no gradient (Fig 1).

View larger version (118K): [in this window] [in a new window]   Fig 1. Two-dimensional Doppler images of the Gor-Tex (W.L. Gore & Assoc, Flagstaff, AZ) interposition graft 2 years after implant. (A) The proximal anastomosis between the left common carotid artery (CCA) and the graft. (B) The distal anastomosis (slightly different plane) between the graft and the left subclavian artery (SUBCLAV). The graft is widely patent.

	Comment

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Ischemic injury to the brachial plexus after SFA was reported by Lawless and colleagues [2]. The left arm was initially completely paralyzed but recovered full function over several months. The vertebral, costocervical, and thyrocervial trunks had been ligated individually. In a reviewers’ comment, Waldhausen [2] believed that the complication was related to the number of branches taken, which he suggested was unnecessary. Although ligation of potential collateral sources has been suggested as a cause for vascular insufficiency after sacrifice of the subclavian, it was not a factor in our case, in which no branches were taken. Though there is the potential for a subclavian steal during exercise of the upper extremity when the vertebral is left intact after subclavian ligation, this is a very rare event. Our policy has been to leave the vertebral intact when interrupting the subclavian.

A number of authors have studied the impact of subclavian ligation on the growth function and blood flow patterns in the ipsilateral extremity. In 1965 Currarino and Engle [3] wrote that interruption of the subclavian could cause a diminution in both longitudinal growth of the long bones and muscle thickness. In their follow-up study of 28 patients, which averaged 8 but extended to 24 years, they concluded that growth disturbance was not consistent, but if present, it was of little clinical importance.

A report by Lodge and colleagues [5] in 1983 reviewed the vascular consequences of subclavian transection in 28 children. Doppler study of the brachial artery showed that over the long term there was a 30% decrease in blood pressure on the operated side. Limb girth also was less. Surprisingly, the data showed no benefit to minimizing ligation of potential collateral vessels although the authors preferred to do so.

Among 16 patients undergoing SFA reported by Todd and coworkers [6], 7 had minor symptoms related to the left upper limb (2- to 9-year follow-up). The majority had a cooler arm, and in 3 patients the extremity was noticeably smaller. Anthropometric measurements showed a minor shortening of the left upper arm in all patients, which the authors believed correlated with observations that upper arm growth tends to predominate in the first years of life, whereas forearm growth is more important later.

There is conflicting evidence with regard to blood flow in the upper limb after SFA. Joyner and associates [7] studied 5 patients 12 to 26 years after subclavian ligation and compared them with 5 matched controls. Using plethysmography they found no difference in forearm flow between operated and control patients both at rest and with maximal exercise. However, van Son and colleagues [4] did observe a decrease in flow in the left brachial artery of 9 SFA patients compared with 14 matched children having coarctation repair by resection and end-to-end anastomosis. Most SFA patients also had a blunted reactive hyperemia response and 2 of 9 had arm claudication with strenuous exercise.

Although highly unusual, symptomatic arm ischemia may result from subclavian ligation even if branches have not been taken. If this occurs our experience suggests that augmentation of blood flow, preferably by direct subclavian-to-carotid anastomosis, or by carotid-subclavian bypass, will be beneficial. The fact that our patient has a fully functional limb speaks to the efficacy of revascularization. Finally, it has been our most recent policy to repair coarctation by resection with extended end-to-end anastomosis whenever possible, thus avoiding the potential complication of subclavian ligation.

	References

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1. Geiss D., Williams W.G., Lindsay W.K., Rowe R.D. Upper extremity gangrene. Ann Thorac Surg 1980;30:487-489.[Abstract]
2. Lawless C.E., Sapsford R.N., Pallis C., Hallidie-Smith K.A. Ischemic injury to the brachial plexus following subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1982;84:779-782.[Abstract]
3. Currarino G., Engle M.A. The effects of ligation of the subclavian artery on the bones and soft tissues of the arms. J Pediatr 1965;67:808-811.[Medline]
4. Van Son J.A., van Asten W.N., van Lier L.K., et al. Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy. Circulation 1990;81:996-1004.[Abstract/Free Full Text]
5. Lodge F.A., Lamberti J.J., Goodman A.H., et al. Vascular consequences of subclavian artery transection for the treatment of congenital heart disease. J Thorac Cardiovasc Surg 1983;86:18-23.[Abstract]
6. Todd P.J., Dangerfield M.B., Hamilton D.J., Wilkinson M.D. Late effects on the left upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1983;85:678-681.[Abstract]
7. Joyner M.J., Chase P.B., Allen H.D., Seals D.R. Response of upper limb blood flow to handgrip exercise after Blalock Taussig operation (for tetralogy of Fallot) of subclavian flap operation (for aortic isthmic coarctation). Am J Cardiol 1989;63:1379-1384.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Winfield J. Wells Luis J. Castro Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wells, W. J. Articles by Castro, L. J. Search for Related Content PubMed PubMed Citation Articles by Wells, W. J. Articles by Castro, L. J.