Pulmonary arterial hypertension (PAH) is a multifactorial heterogeneous condition characterized by elevated pulmonary artery pressure, leading to increased right ventricular afterload and ultimately resulting in right heart failure. Despite major advances in the management of pediatric PAH in recent years with the development of PAH-specific drug therapy and therapeutic strategies, prognosis still remains unsatisfactory for many children. The Potts shunt, as a palliation in patients with cyanotic congenital heart defects first, receives its 'second life' in treating PAH by creating a shunt between the pulmonary artery and the descending aorta to alleviate right heart burden. Over the past 20 years, accumulated clinical experience have revealed that reverse Potts shunt (RPS) can effectively improve cardiac function and survival time in PAH patients, with midterm survival rates comparable to those of lung transplantation. However, RPS is confronted with some issues that limit its development and application in clinical practice, such as identifying the suitable patient population, determining the optimal timing of intervention, and selecting the appropriate shunt type and size. This review aims to retrospectively summarize the experience of RPS in the treatment of PAH, discuss the main challenges faced in its clinical application, and help to guide clinical practice.