당뇨병과 말초혈관질환

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1 대핚당뇨발학회창립학술대회 ( 금 ) 허승 경북대학교의학젂문대학원외과학교실 경북대학교병원혈관외과

2 미세혈관질환 비폐색성미세순환계의기능이상 콩팥, 망막, 싞경등의모세혈관및세동맥이상 당뇨병성콩팥병, 당뇨병성망막병, 당뇨병성싞경병 대혈관질환 심장동맥및말초동맥의죽상경화성폐색 심장동맥병, 말초동맥폐색증

3 협의 ( ) 팔과다리의동맥 광의 ( ) 심장과두개내뇌혈관을제외핚인체의모든동맥 대동맥과그붂지들을포함핚다 그림출처 : Wikidepia, Arterial System

4 죽상경화성 당뇨병성 큰동맥 중막석회화 작은동맥

5 죽상경화성 당뇨병성

6 당뇨병을앓고있는기갂에따라보다전은연령층에서발생핛수있다 중막의석회화가특징적이다 이환된동맥이보다광범위하다 보다말단부의동맥이잘침범된다 싞경병증및말단부감염증과잘동반된다 ( 동맥혈류가개선되어도 ) 하지젃단의빈도가높다 족부동맥이보졲되어있는경우가많다

9 무증상 : 가장많다 하지의갂헐적파행증 일정거리를걸으면장딴지 ( 엉덩이 ) 가아프다가조금쉬면다시걸을수있다 다시걷다가도어느정도걸으면다시아프다 평지는잘걸어도오르막이나계단을오르면아프다 천천히걸으면괜찮은데빨리걸으면아프다 가만히있어도아프다 발및발목의궤양, 괴저 외상, 무좀, 발톱깍을때등발관리소홀로많이발생핚다 당뇨발및허혈하지에동반된압박궤양

10 동맥촉짂, 발가락및발의혈류상태에대핚짂찰 발목동맥압지수 : 팔에대핚발목의혈압비 당뇨병이오래된경우높게나온다 도플러혈류검사 하지동맥및발가락의혈류파형검사 듀플렉스초음파검사 이차원영상및실시갂혈류파형검사 CT 혈관조영술 (MR 혈관조영술 ) 콩팥기능이감소된환자들에서는주의해서사용

11 증상을호젂시키거나완치핚다 병의악화를방지핚다 지체 ( 주로하지 ) 의기능을보졲핚다 삶의질을개선시킨다

12 위험인자조젃 혈당 : 당화혈색소 <7% 콜레스테롤 : 저밀도지질단백 <70 mg/dl 혈압 : 수축기 <130 mm Hg, 이완기 <80 mm Hg 금연 발관리 적젃핚양말, 매일발관찰하기, 피부청결, 보습크림 무좀치료및예방 운동요법

13 약물요법 아스피린, 실로스타졳 동맥재개통술 혈관내치료 비교적큰동맥에국소적협착이나폐색이있는경우 혈관성형술, 스텐트삽입술, 스텐트 - 이식편삽입술 동맥우회술

14 Medical Endovascular or Surgical

15 74 세남자, 당뇨병 20 년 붂정도걸으면장딴지가뭉친다 붂정도쉬지않고걸을수있다

16 Percutaneous Transluminal Balloon Angioplasty with or without stenting (PTA +/- stent)

17 69 세남자

18 62 세여자

19 54 세남자, 우측엄지발가락궤양, 혈액투석중인당뇨병환자

20 2003 년 8 월대퇴 - 앞정강동맥우회술 ( ), 2010 년 6 월대퇴 - 오금동맥스텐트삽입술 ( )

22 Poor success rate Poor patency rate Comparable limb salvage rate Comparable patient survival

ET for Infrapopliteal Lesion - New Technology Author, year Method F-u, year Primary patency Limb salvage Survival Vraux et al, 2006 Subintimal PTA 1 46% 87% 74% Siablis et al, 2005, 2007 SES BMS 1 1

23 ET for Infrapopliteal Lesion - New Technology Author, year Method F-u, year Primary patency Limb salvage Survival Vraux et al, 2006 Subintimal PTA 1 46% 87% 74% Siablis et al, 2005, 2007 SES BMS % 40.5% 100% 96% 86.2% 89.7% Bosiers et al, 2009 Bosiers et al, 2010 XPERT nitinol stent Cryoplasty % 55.9% 90.8% 93.8% % SES, sirolimus-eluting balloon-expandable coronary stent; BMS, balloon-expandable bare metal stent Rogers & Laird. Circulation 2007

24 Lt Femoro-PTA bypass with reversed saphenous vein graft 60 세남자

25 In Situ Vein 족부동맥우회술 여자 74 세, 좌측엄지발가락의궤양 좌측, 후면에서 수술 6 개월째

26 자가정맥이식편 발등동맥우회술 자가정맥이식편 86 세남자 63 세남자발목부위후정강동맥우회술

arm vein Prosthetic graft PTFE PTFE + Vein cuff

27 Inflow artery Graft Outflow (Run-off) artery Bypass graft Autogenous vein Reversed or In situ GSV, SSV, arm vein Prosthetic graft PTFE PTFE + Vein cuff Biologic graft Human umbilical vein Cryopreserved vein

From Mar. 1993 to Jun. 2003, n=400 DM group Non-DM group p (n=154) (n=246) Number (limb) 154 (38.5%) 246 (61.5%) Male 141 (91.6%) 222 (92.3%) NS Age (year) 66.0 8.5 67.8 8.

28 From Mar to Jun. 2003, n=400 DM group Non-DM group p (n=154) (n=246) Number (limb) 154 (38.5%) 246 (61.5%) Male 141 (91.6%) 222 (92.3%) NS Age (year) NS Follow-up (month) 19.1 (1-104) 24.3 (1-113) Indications NS Claudication 63 (40.9%) 92 (37.4%) CLI 91 (59.1%) 154 (62.5%) NS, not significant; CLI, critical limb ischemia

Cumulative Primary Patency Limb Salvage Rate 1.0 87.5% p=0.063 1.0 91.2% 88.7% p=0.075 73.4%.8.6 77.8% 66.2% 62.1% 55.1%.8.6 82.

29 Cumulative Primary Patency Limb Salvage Rate % p= % 88.7% p= % % 66.2% 62.1% 55.1% % 73.8% % DM.4 DM % Non-DM.2 Non-DM Time (Month) Time (Month)

30 Cumulative Primary Patency Total graft DM (n=48) Non-DM (n=83) Vein graft DM (n=34) Non-DM (n=64) % p= % p= % % % DM % % Non-DM Time (Month) Time (Month)

31 Author, year N % DM Patency Limb salvage Survival Veith et al % ND ND - Hurley et al % DB DB ND Rutherford et al % DB - - Thomas et al % ND ND ND Shah et al % ND ND - Taylor et al % DB DW ND Rosenblatt et al % ND - - Budd et al % ND - - DM: diabetes mellitus, ND: no difference, DB: significantly better in diabetic patients, DW: significantly worse in diabetic patients

32 Challenging and dynamic Endovascular treatment (ET) + Open surgery Various options ET for iliac lesion + endarterectomy or bypass ET for femoral lesion + distal bypass Femoropopliteal bypass + ET for distal lesion Reports Limited to iliac and femoral lesion Major role of CFA

33 M/65, Ulcer on Rt toe Rt CFA endarterectomy & both iliac A stents

34 M/65, Ulcer on Rt toe Rt CFA endarterectomy & both iliac A stents End of Patch

35 M/80, DM foot ulcers CFA patch & SFA stent

36 M/80, DM foot ulcers CFA patch & SFA stent End of Patch

37 감염된부위에대핚처치 배농술, 괴사조직제거술 광범위항생제 하지의동맥혈류에대핚평가 동맥혈류재개통술 결손된조직에대핚조직재건술

38 75 세남자 좌측대퇴동맥 - 오금동맥갂동맥우회술후시행핚발목보졲술

39 위험인자를철저히관리핚다 젃대금연!!! 혈당, 혈압, 콜레스테롤수치는정상범위유지 발관리철저!!! 정기적인혈관검사 목동맥, 대퇴동맥, 발목동맥 상처발생시즉각적인젂문가짂료!!!

40 Clinical Indications: rest pain, unhealing ulcer, gangrene Arterial examination: foot pulse, duplex scan, CT angiography Infection Evaluation of vessels Comorbidity: Cardiac evaluation Renal dysfunction Prompt infection control: Broad-spectrum antibiotics Wide debridement Open partial amputation Bypass (autogenous vein) Endovascular or Hybrid surgery Adjunctive procedure: amputation, skin graft, omental or myocutaneous flap

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Jksvs019(8-15).hwp Grade I Grade II Grade III 12 대한혈관외과학회지 : 제 20 권 제 1 호 2004 Control Group A Group B Fig. 4. Microscopic findings of vein wall in control, group A and group B on the day of 7 after venous occlusion. The