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1 대한내과학회지 : 제 87 권제 6 호 급성대동맥박리가강으로좌측총장골동맥폐색시흉부대동맥스텐트로치료한 1예 부산대학교의학전문대학원부산대학교병원순환기내과심혈관센터 양미진 장혜윤 최종현 전무송 이혜원 이한철 김상필 Complicated Acute Aortic Dissection with Malperfusion of the Left Common Iliac Artery Treated with Thoracic Endovascular Aortic Repair Mi Jin Yang, Hye Yoon Jang, Jong Hyun Choi, Moo Song Jeon, Hye-Won Lee, Han Cheol Lee, and Sang-Pil Kim Division of Cardiology, Cardiovascular Center, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea Acute aortic dissection with malperfusion syndrome is associated with poor clinical outcomes, and surgical treatment for complicated descending aortic dissections is associated with a high risk of operative mortality. Endovascular repair is emerging as a good alternative to surgery. Endovascular repair for a descending aortic dissection with malperfusion syndrome offers good clinical outcomes because of technical and anatomical benefits. Here, we report a case of descending aortic dissection and malperfusion syndrome in the left common iliac artery that was successfully treated with an aortic stent graft and peripheral stent. (Korean J Med 2014;87: ) Keywords: Aorta; Aortic dissection; Stents; Malperfusion 서론급성대동맥박리 (acute aortic dissection) 는초기사망률이매우높은질환이며대동맥박리의침범부위에따라치료방법이결정된다. 일반적으로상행대동맥박리 (ascending aortic dissection) 의경우수술적치료, 하행대동맥박리 (descending aortic dissection) 의경우약물치료가적용이된다. 그러나약물치료의적응증이되는하행대동맥박리의경우라도직경이큰대동맥류 (aneurysm), 대동맥파열 (aneurysmal rupture), 경동맥 (carotid artery), 상장간막동맥 (superior mesenteric artery), 복강동맥 (celiac artery), 신장동맥 (renal artery), 장골동맥 (iliac artery) 등의혈류장애등의합병증이발생하는경우는수술 Received: Revised: Accepted: Correspondence to Sang-Pil Kim, M.D. Division of Cardiology, Cardiovascular Center, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan , Korea Tel: , Fax: , nicecure@daum.net Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - Mi Jin Yang, et al. Aortic dissection endovascular repair - 이나혈관내시술 (endovascular procedure) 을시행해야한다 [1,2]. 대동맥박리에서가강 (false lumen) 에의하여주요혈관에폐색이동반된다면과거에는수술적치료를고려하였지만, 성적이좋지않아서현재에는혈관내시술을시행하여서좋은결과를보이고있다. 합병증을동반한하행대동맥박리에서흉부대동맥혈관내치료 (Thoracic endovascular aortic repair, TEVAR) 는최근수술과비교하여안정성및단기성적에있어오히려우수하다는다수의보고가보이고있다 [3-7]. 저자들은하행대동맥박리에의하여가강이진강 (true lumen) 을눌러서좌측총장골동맥 (left common iliac artery) 폐색을유발한증례에서흉부대동맥혈관내치료와좌측총장골동맥내스텐트 (stent) 삽입을시행하여성공적으로치료한증례를보고한다. 증례 시함이관찰되었다. 그러나신장동맥아래의대동맥부위는가강에의해진강이눌려지는소견을보였다. 우측총장골동맥은가강에서기시하였다. 좌측총장골동맥은진강이가강에의해완전히눌려서혈류가소실된소견이관찰되었다 (Fig. 1). 검사실소견 : 내원당시심전도상 III, avf 유도에서 T파전위가보였으며기타특이소견은보이지않았다. 혈액검사상혈색소, 간기능검사및신기능검사, 전해질수치및염증수치, 심근효소검사상특이소견이관찰되지않았다. A B 환자 : 60세남자주소 : 등부위및왼쪽하지의통증현병력 : 흉통및등부위통증으로타병원에서관상동맥촬영, 심장초음파검사를시행하였고정상소견을보였다. 내원 3일전부터계속심해지는등부위의통증과왼쪽하지의파행과색조변화로본원을방문하여시행한컴퓨터단층촬영 (computerized tomography, CT) 검사상하행대동맥박리 (stanford type B) 소견을보여서입원하였다. 과거력및가족력 : 60갑년의흡연력과음주력이있으며 3 년전고혈압진단이후투약은하지않았고, 당뇨와심근경색가족력이있었다. 이학적검사 : 내원당시혈압은 120/80 mmhg, 맥박수분당 80회, 호흡수분당 23회, 말초산소포화도 97%, 체온 36 였다. 흉부진찰상심잡음은들리지않았고정상폐음소견을보였다. 복부및사지진찰상좌측족배동맥 (left dorsalis pedis artery) 은잘촉지되지않았고좌측하지의피부는차가웠고색조변화가있었다. 방사선소견 : 흉부방사선검사상종격동의확장및대동맥의굴곡이심한상태가관찰되었다. 입원당시에시행한컴퓨터단층촬영소견상흉부대동맥에서원위부대동맥분지부 (distal aortic bifurcation) 까지대동맥박리가관찰되며상장간맥동맥은진강과가강에서같이기시하였으나혈류는원활하게유지되었다. 복강동맥, 양측신장동맥은진강에서기 C E Figure 1. Baseline CT. (A) The intimal tear site was located in the mid-thoracic aorta. (B) The superior mesenteric artery arose from the true lumen and false lumen. (C) Both renal arteries arose from the true lumen. (D) The true lumen of the distal aorta was collapsed by the false lumen. (E and F) Reconstructed CT images. (E) The intimal tear site was seen in a coronal image of the mid-thoracic aorta. (F) The left common iliac artery was collapsed by the false lumen, and the right common iliac artery arose from the false lumen. D F

- 대한내과학회지 : 제 87 권제 6 호통권제 652 호 2014 - A B C D Figure 2. The endovascular procedure.

(B) An aortic stent graft was positioned in the intimal tear site at the mid-thoracic aorta.

(D) Restoration of blood flow in the true lumen of the left and right common iliac arteries after thoracic

3 - 대한내과학회지 : 제 87 권제 6 호통권제 652 호 A B C D Figure 2. The endovascular procedure. (A) The collapsed true lumen was seen at the distal aorta by aortography. (B) An aortic stent graft was positioned in the intimal tear site at the mid-thoracic aorta. (C) A thoracic aortic graft was deployed to seal off the intimal tear site. (D) Restoration of blood flow in the true lumen of the left and right common iliac arteries after thoracic endovascular aortic repair (TEVAR). 치료및경과 : 입원직후양측발목상완지수 (Ankle-brachial index, ABI) 는오른쪽과왼쪽이각각 0.91, 0.25로왼쪽하지에서많이감소하여있었다. 대동맥박리급성기에혈관내시술을피하기위하여혈압조절및맥박조절을하며약물치료를먼저시행하였으나 5일뒤왼쪽하지의통증과색조변화가증가하는소견을보여서불가피하게흉부대동맥혈관내치료와좌측총장골동맥스텐트삽입술을시행하였다. 좌측대퇴동맥을천자하였으나가강에의해진강이협착되어있는관계로가강으로천공되었다가다시시도하여진강을천자한후 inch 유도철사 (guide wire) 를완전협착된좌측총장골동맥및복부대동맥 (abdominal aorta) 으로조심스럽게진행시킨후 6 french, 25 cm 장유도초 (long sheath) 를복부대동맥내로위치시킨후유도초를통한조영술을실시하여진강에서기시하는신장동맥을볼수있어서진강으

- 양미진외 6 인. 급성대동맥박리스텐트이식편삽입술 - 로유도철사가위치하였음을확인하였다 (Fig. 2A and 2B). 0.035 inch 유도철사와다용도카테터 (multipurpose catheter) 를상행대동맥으로진행시킨후표식자돼지꼬리형카테터 (marked pigtail catheter) 로대동맥조영술 (aortography) 을시행하였다.

4 - 양미진외 6 인. 급성대동맥박리스텐트이식편삽입술 - 로유도철사가위치하였음을확인하였다 (Fig. 2A and 2B) inch 유도철사와다용도카테터 (multipurpose catheter) 를상행대동맥으로진행시킨후표식자돼지꼬리형카테터 (marked pigtail catheter) 로대동맥조영술 (aortography) 을시행하였다. 하행대동맥의중간부분에서내막파열부위 (intima tear site) 가있었고가강에의하여진강이완전히눌려서원위부대동맥에서좌측총장골동맥으로가는혈류는없었다. 우측총장골동맥은가강을통하여혈류가공급되었다. 이후흉부대동맥내의내막파열부위에스텐트이식편 (stent graft) 삽입술을시행하였다. 혈관내시술직후바로진강이확장되었고좌측총장골동맥의혈류가재개통되었다. 그러나일부남아있는협착부위에혈류회복을위하여 8 mm 100 mm self expandable nitinol stent (S.M.A.R.T., Cordis, Bridgewater, A B C D NJ, USA) 를좌측총장골동맥기시부에삽입하였다 (Fig. 2D). 시술후가강에서혈류가가던우측총장골동맥은진강이점차넓어져가는소견을보여서경과를관찰하다가오른쪽하지에허혈등의증상이있을때 2차시술을하기로하고시술을마쳤다. 시술을마친이후혈액검사및활력징후상혈류폐색및장기손상의근거를보이는이상소견은관찰되지않았고 7일뒤시행한컴퓨터단층촬영에서가강의감소와좌측총장골동맥의혈류회복이관찰되었다. 상완발목지수에서우측은 0.6으로감소하였으나좌측은 1.04로성공적인혈류재개통이있음을확인할수있었다. 환자는특별한증상이나합병증없이퇴원하였다. 시술전에는항혈소판제를사용하지않았으나우측총장골동맥에스텐트를삽입하여서시술후에는 aspirin 과 clopidogrel을사용하였다. 퇴원후 24개월동안특별한증상이나하지의파행 (claudication) 은없었고시행한상완발목지수에서우측이 0.67, 좌측 1.18로좌측하행혈류가정상화된것을확인할수있었으며우측혈류도더이상의감소를보이지않고호전되어가는것을확인할수있었다. 그리고컴퓨터단층촬영에서하행대동맥과양측장골동맥내의가강폐쇄및좌측총장골동맥의혈류가원활하게유지됨을확인하였다 (Fig. 3). 고찰 E Figure 3. Follow-up CT images after 2 years. CT images showing remodeling of the thoracic aorta after TEVAR. The flow of blood in the distal aorta and left common iliac artery was greatly improved after 2 years. F 급성대동맥박리는대동맥내막의찢어진부위를통해혈액이대동맥중막 (media) 내로들어가며대동맥이박리되는질환이며, 유병률은 10만명에서연당 3건가량되며발견된이후초기사망률및치료를받지못했을경우의사망률이매우높은고위험질환이다 [1,2]. 일반적으로치료를결정할때가장중요한것은상행대동맥침범여부이며, 상행대동맥박리가있으면심장압전 (cardiac tamponade) 으로진행하여급사의위험성이있기때문에응급수술을시행하여야한다. 하행대동맥박리의경우합병증이동반되지않으면약물치료를하지만, 가강에의하여진강에눌려서상장간막동맥, 복강동맥, 신장동맥, 하지로가는동맥이눌려서장, 신장, 간, 하지에허혈이발생하면응급으로수술이나시술을통한혈류의회복이필요하고이러한경우에는높은사망률을가지는것으로보고되고있다. 가강에의하여진강이눌려서생기는관류장애 (malperfusion) 의경우에는수술적치료가해부학적으로어렵고사망률이매우높은것 (25-50%) 으로보

5 - The Korean Journal of Medicine: Vol. 87, No. 6, 고되고있다 [8,9]. 그이유는가강에의하여진강이눌려서상장간막동맥, 신장동맥, 복강동맥, 장골동맥이허혈이발생하는경우에는수술시에복부를절개하고장을젖힌후에야하행대동맥의수술시야가어렵게확보되고수술시에찢어진하행대동맥에서가강과진강은육안으로구별하기어렵기때문이다. 따라서정확히하행대동맥진강에서상장간막동맥, 신장동맥, 내장동맥, 장골동맥의진강으로연결하는우회로수술 (bypass surgery) 을하는것은기술적으로어려우며높은수술사망률을보이고있다. 대동맥박리에동반된관류장애에대한혈관내시술이수술에대한대안으로소개되고있으며그방법은다양하다. 혈관내시술은크게 3가지정도의치료방법으로나누어진다 [8]. 첫번째는스텐트이식편을내막파열부위에삽입하여가강으로가는혈류를차단하여진강을회복시켜서혈류를회복시키는방법이가장보편적으로이루어지고있고좋은성적을보이고있다. Nienaber 등 [7] 이조사한메타연구에따르면대동맥박리에동반된관류장애시에혈관내시술을시행하였을때혈류회복에성공하는것은 95% 이고사망률은 11% 로좋은성적을보고하였다. 두번째는가강에의하여혈류가차단된각각의혈관에스텐트삽입을시행하는것이다. 가강에의하여눌려진신장동맥, 상장간막동맥, 장골동맥, 복강동맥에진강에서가강을가로질러서스텐트를각각의동맥에연결하는스텐트시술을하는방법도소개되었고시행되고있다. 세번째는과거에많이시행되었던방법으로가강과진강을큰풍선카테터 (balloon catheter) 를통하여창냄 (fenestration) 시술을시행하는것이다. 그러나장기간의경과관찰시에창냄시술은하행대동맥류 (descending aortic aneurysm) 발생과하행대동맥파열 (descending aortic rupture) 이발생하는경우가많이보고되고있어서현재에는활발히시술되지않고있다 [8]. 앞의세가지시술방법들을통하여하행대동맥박리에따른관류장애증후군 (malperfusion syndrome) 환자의성적을대규모등록연구인 Interrnational Registry of Acute aortic Dissection (IRAD) 결과를보면병원내사망률에있어서수술과비교할때수술보다유의하게뛰어난성적을보이고있다 [3]. 그리고혈관내시술시에수술에비하여생존율및합병증에서뛰어난성적이증명되었으나장기예후에대한자료는아직은부족한실정이다. Zeeshan 등 [6] 에따르면하행대동맥박리에동반된관류장애증후군시에는혈관내시술을먼저시행하여볼 것을권하고있다. 본증례에서는하행대동맥의중간부위인상장장간막동맥의 20 cm 위에서내막파열이발생하였고가강을통한혈류가증가하면서진강이아래쪽으로심하게눌려좌측총장골동맥부터는진강이완전폐색이되어서하지에허혈을유발하고있었고우측하지는가강에서혈류가공급되는상태였다. 이경우우측대퇴동맥을통한시술을시행하는시에는가강을통하여유도철사가진행하므로시술이성공할수없기때문에좌측대퇴동맥을천자하여서눌려진진강으로유도철사를통과시켰다. 신장동맥은진강에서기시하므로 25 cm 길이의장유도초를통하여대동맥조영술을시행한후신장동맥을확인하였고진강안에유도철사가있는것을확인한후스텐트이식편을진행시켜서내막파열부위를막았다. 좌측총장골동맥은완전폐색처럼보이지만, 가강에의하여진강이눌린것이므로스텐트이식편은쉽게하행대동맥으로진행하였다. 그러나좌측대퇴동맥으로도유도철사가진강으로진행이되지않는경우는좌측상완동맥을통한접근도고려해야겠다. 본증례에서는스텐트이식편삽입후좌측총장골동맥에남은협착이있어서스텐트시술을하였고우측총장골동맥의경우에는가강에서혈류를공급받았으나스텐트이식편시술후에는진강혈류가증가하여가강과진강에서혈류를공급받았다. 환자는우측하지의증상을호소하지않았으며발목상완지수도 0.6 이상측정되어서경과관찰후하지에파행 (claudication) 을호소하는경우에추가적인시술을하려고계획하였으나 24개월동안증상없이발목상완지수가 0.67로호전되었다. 본증례에서는가강에의하여진강이눌려서하지혈관폐색이동반된하행대동맥박리에서스텐트이식편치료를통하여진강의혈류를회복시켜서효과적으로치료한증례이다. 요약관류장애를동반한하행대동맥박리의경우수술적인치료시에높은사망률을보인다. 이증례는가강에의하여진강이눌려서좌측총장골동맥으로의혈류가폐색된경우이고스텐트이식편을하행대동맥의내막파열부위에삽입하여서진강의혈류를회복시켜서좌측총장골동맥의혈류를복원하였고 24개월동안경과관찰시에이상소견없이유

6 - Mi Jin Yang, et al. Aortic dissection endovascular repair - 지되었다. 저자들은하행대동맥박리에동반된하지혈관의관류장애시에스텐트이식편치료로효과적이고안전하게치료된증례 1예를경험하였기에보고한다. 중심단어 : 급성대동맥박리 ; 하행대동맥박리 ; 주요혈관폐색 ; 흉부대동맥혈관내치료 REFERENCES 1. De León Ayala IA, Chen YF. Acute aortic dissection: an update. Kaohsiung J Med Sci 2012;28: Nienaber CA, Powell JT. Management of acute aortic syndromes. Eur Heart J 2012;33:26-35b. 3. Fattori R, Tsai TT, Myrmel T, et al. Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv 2008;1: Verhoye JP, Miller DC, Sze D, Dake MD, Mitchell RS. Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting. J Thorac Cardiovasc Surg 2008;136: Patel HJ, Williams DM, Meerkov M, Dasika NL, Upchurch GR Jr, Deeb GM. Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: implications for thoracic aortic endovascular repair. J Thorac Cardiovasc Surg 2009;138: Zeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg 2010;140(6 Suppl):S Nienaber CA, Kische S, Ince H, Fattori R. Thoracic endovascular aneurysm repair for complicated type B aortic dissection. J Vasc Surg 2011;54: DiMusto PD, Williams DM, Patel HJ, Trimarchi S, Eliason JL, Upchurch GR Jr. Endovascular management of type B aortic dissections. J Vasc Surg 2010 ;52(4 Suppl):26S-36S. 9. Sandridge L, Kern JA. Acute descending aortic dissections: management of visceral, spinal cord, and extremity malperfusion. Semin Thorac Cardiovasc Surg 2005;17:

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<313220C1F5B7CA D B9DABFB5C1D62DC0CCC7D1C3B62E687770> 대한내과학회지 : 제 90 권제 5 호 2016 http://dx.doi.org/10.3904/kjm.2016.90.5.433 대동맥박리에서가강에의해장골동맥폐색시좌측상완동맥을통한스텐트시술 부산대학교의학전문대학원부산대학교병원순환기내과심혈관센터 박영주 이정은 강진숙 장희령 김민지 김상필 이한철 Type B Aortic Dissection with Malperfusion