Risk-adapted first-stage patent ductus arteriosus ligation for an anomalous left brachiocephalic trunk arising from the main pulmonary artery in a critically ill neonate: a case report and literature review

Introduction and importance: Anomalous origin of the brachiocephalic trunk from the main pulmonary artery (MPA) is an exceptionally rare congenital vascular anomaly. Management is not standardized, particularly in critically ill neonates. Case presentation: A female neonate developed acute respiratory distress after birth. Echocardiography showed an atrial septal defect and a patent ductus arteriosus (PDA). Follow-up echocardiography and computed tomography angiography confirmed a right-sided aortic arch, a right-sided PDA, and an anomalous left brachiocephalic trunk arising from the MPA. The course was complicated by active infection, mechanical ventilation, liver cirrhosis, thrombocytopenia, and coagulopathy. After multidisciplinary review, PDA ligation alone was selected as a first-stage stabilization strategy to eliminate the dominant left-to-right shunt. Median sternotomy allowed exposure of the right-sided PDA and great vessels. The PDA was ligated without cardiopulmonary bypass, and the anomalous vessel was preserved. Complete PDA closure and temporary hemodynamic improvement were observed. However, after transfer back to the referring hospital, the patient died before second-stage reconstruction could be performed. Clinical discussion: Reported strategies include vessel ligation and single-stage anatomical repair. In this neonate, definitive reconstruction was deferred because of severe systemic comorbidities and poor physiological reserve. PDA ligation may provide temporary hemodynamic stabilization in critically ill neonates; however, it did not correct the anomalous vascular anatomy or establish long-term perfusion of the cerebral circulation and the left upper extremity. Conclusion: Treatment should be individualized according to physiological reserve. PDA ligation alone may be considered as a temporary, risk-adapted first-stage stabilization in selected high-risk neonates when complete correction is unsafe.