Original Articles 대동맥궁이상을가진영유아에서의말초동맥을 Abstract 이용한역류성대동맥조영술 김영휘 고재곤 박인숙 홍창의 Counter-Current Aortography Using Peripheral Arteries in Small

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1 Original Articles 대동맥궁이상을가진영유아에서의말초동맥을 Abstract 이용한역류성대동맥조영술 김영휘 고재곤 박인숙 홍창의 Counter-Current Aortography Using Peripheral Arteries in Small Infants and Neonates with Aortic Arch Obstruction Young-Huwe Kim, M.D., Jae-Kon Ko, M.D., In-Sook Park, M.D., Chang-Yee Hong, M.D., Department of Pediatric Cardiology, University of Ulsan-College of Medicine, Asan Medical Center, Seoul, Korea BackgroundDiagnosis of aortic arch obstruction can be made with two-dimensional and Doppler echocardiography in most cases. However, not infrequently, clear imaging of the aortic arch can not be obtained, particularly in sick neonates and young infants from a number of reasons and heart catheterization and angiography carries significant risk in sick babies. Therefore it is the purpose of this study to assess the feasibility and safety of counter-current aortography through a peripheral artery in young infants and neonates with suspected aortic arch obstruction. MethodsWe studied 56 patients with suspected aortic arch anomaly at Asan Medical Center from February 1990 to April First choice for the peripheral artery was radial artery on the same side as the aortic arch, followed by brachial artery and axillary artery. Small 24 gauge plastic cannula was inserted and special attention was given to ensure that the peripheral artery, plastic cannula, and a syringe containing contrast material are all in the same plane. 1ml/kg of contrast material was injected by rapid hand injection and biplane cineangiograms were taken at 60 frame/second. ResultsFifty six patients underwent 58 angiograms. Age ranged from 5255 daysmedian 30 days and body weight nanged from kgmean 3.4 kg. There were 27 males and 29 females. Arteries used wereradial artery in 37, brachial artery in 19, and axillary artery in 2 cases. Peripheral arteries were ipsilateral side as the aortic arch in 54, contralateral side in 2 and bilateral in 2 cases. In 8 patients heart catheterization was done because of inadequate visualization of aortic arch anatomy and/or need for evaluating other defects. In 48 patients who had periperal angiography only, fluoroscopic time ranged from 0.6 to 3.5 minutes and total procedure time ranged from 10 to 15 minutes. Among these 48 patients, only 11 patients23% were given intraveous sedation and 37 patients77% did not receive any sedation. Diagnosis of aortic arch anomaly was aortic coarctation in 38, aortic interruption in 10 and normal aortic arch in 8 patients. Aortic arch anatomy was well 839

2 demonstrated in all cases where injected artery was on the same side as the aortic arch. In patients who had angiograms through peripheral arteries contralateral to the side of the aortic arch did not have adequate visualization of the arch. Compression of the carotid artery did not enhance the imaging of the arch. Simultaneous bilateral angiography did not improve the imaging quality as compared to ipsilateral artery angiography. Transient complication, related to cannulation, e.g., prolonged bleeding was seen in only one patient with aortic interruption. Circulation on the upper extremities was normal after angiography in all patients. ConclusionCounter-current aortography using 24 gauge plastic cannula through peripheral artery is feasible, rapid, safe, economic and relatively non-invasive procedure and provides adquate imaging of aortic arch obstruction in infants and neonates without risk of heart catheterization and angiography. We, therefore, recommend this procedure in selected patients in whom echocardiographic imaging alone is not conclusive for planning corrective surgery. KEY WORDSRadial artery Counter-current aortography Aortic arch obstruction Congenital heart diseaseinfants Neonates. 서론 연구대상및방법 840

3 결과 Table 1. Summary of cardiac diagnosis Cardiac diagnosis Number of patients COA Isolated 3 COA with VSD 23 MS 2 VSD, MS 1 AS 1 VSD, AS 1 ASD 3 AVSD 2 LTGA, DILV 2 IAA with VSD 4 AP window 2 LTGA, VSD 2 DTGA, VSD 1 Taussig-Bing 1 Normal Arch with TAPVR 1 Taussig-Bing 1 VSD 6 AbbreviationsCOAcoarctation of the aorta, VSD ventricular septal defect, MSmitral stenosis, AS aortic stenosis, ASDatrial septal defect, AVSD atrioventricular septal defect, LTGAcongenitally corrected transposition of the great arteries, DILV double inlet left ventricle, AP windowaortopulmonary window, TAPVRtotal anom-alous pulmonary venous return 841

차이는 없었다. 서 동시에 조영술을 실시하였으나 대동맥궁과 같은쪽 두 예에서는 양측 요골동맥에서 동시에 조영술을 에서만 시행한 조영술과 진단적 차이는 없었다.

AP and lateral views of counter-current aortography through left radial artery showing normal aortic arch and descending

Angiogram through left radial artery injection showing discrete COA(arrowhead) and hypoplastic isthmus. There is no PDA.

4 차이는 없었다. 서 동시에 조영술을 실시하였으나 대동맥궁과 같은쪽 두 예에서는 양측 요골동맥에서 동시에 조영술을 에서만 시행한 조영술과 진단적 차이는 없었다. 수술 실시하였고 다른 한 예에서는 요골동맥과 제대동맥에 전에 역류성 대동맥 조영술을 시행받았던 한 환자에 Fig. 1. AP and lateral views of counter-current aortography through left radial artery showing normal aortic arch and descending aorta in a 5-day-old baby with large perimembraneous VSD. Fig. 2. Angiogram through left radial artery injection showing discrete COA(arrowhead) and hypoplastic isthmus. There is no PDA. Mild poststenotic dilatation of descending aorta is seen. Fig. 3. AP and lateral views of severe COA associated with long tubular hypoplasia of aortic isthmus (arrowhead)seen by left radial artery injection in a 15-day-old bady with large subarterial VSD. 842

Lateral angiograpms of left radial artery injection in a 7-day-old baby with COA(arrowhead), large VSD and large PDA(asterisk). Note that size of PDA is same as descending aorta.

5 Fig. 4. AP and lateral views of right brachial artery angiogram in a 25-day-old bady with severe COA and left aortic arch. Note that COA is not seen. Instead large multiple collateral arteries are seen opacifying descending aorta distal to COA. Fig. 5. Lateral angiograpms of left radial artery injection in a 7-day-old baby with COA(arrowhead), large VSD and large PDA(asterisk). Note that size of PDA is same as descending aorta. 서는 대동맥축착 수술 6일 후 요골동맥 조영술을 다 에서는 동맥관 근처의 하행 대동맥에서 대동맥 축착 시 실시하여 정상으로 교정된 동맥궁이 잘 보였다. 시에 특징적으로 보이는 전 심장주기에서 지속적으로 대동맥 축착환자 38예중 대동맥 협부(aortic isth- 감지된 높은 속도의 비정상혈류가 발견되어 요골동맥 mus)의 심한 관상 형성부전(tubular hypoplasia)이 조영술을 실시한 결과 대동맥은 정상임이 확인되었다. 동반된 경우가 20예, 약간의 형성부전이 6예이었고 따라서 이와같은 높은 속도의 비정상 혈류양상은 폐동 나머지 12예에서는 대동맥 협부가 정상이었다. 맥 압력(100mmHg)이 하행 대동맥압력(50mmHg) 여러개의 큰 측부동맥(collateral arteries)들이 대 동맥축착 38예중 13예에서, 그리고 동맥궁 단절 10 예중 3 예에서 잘 발달되어 있었으며(Fig. 4) 나머지 보다 매우 더 높았던 이 환자에서 동맥관이 좁아지면 서 이를 통한 와류로 인한 것으로 확인되었다. 말초동맥 조영술의 합병증은 대동맥궁 단절을 가졌 던 한 예에서만 있었는데 도관을 제거한 후에 요골동 환자들에서는 측부혈관들이 비교적 작았다. 폐정맥 혈류의 협착으로 인하여 심한 폐동맥 고혈 맥에서의 지혈이 안되고 PT, PTT가 연장되어 신선냉 압이 동반된 전폐정맥 환류이상이 있었던 한 신생아 동 혈장을 주사한 후에 지혈되었으며 나머지 55명에 843

Fig. 6. AP and lateral views of left radial artery angiogram in a bady with IAA type A(interruption distal to left subclavian artery) and left aortic arch.

AP view of aortogram in a 15-day-old baby with right aortic arch and IAA type B(interruption between right subclavian and right common carotid artery).

First branch from the right aortic arch was left innominate artery(abbreviations LSCA left subclavian artery, LCCA left common carotic artery, RCCA right common carotid artery, LCA left coronary

6 Fig. 6. AP and lateral views of left radial artery angiogram in a bady with IAA type A(interruption distal to left subclavian artery) and left aortic arch. Descending aorta is not visualized and there is scanty collateral arteries. Fig. 7A. AP view of aortogram in a 15-day-old baby with right aortic arch and IAA type B(interruption between right subclavian and right common carotid artery). Note that this angiogram through left radial artery did not show descending arota and right subclavian artery. First branch from the right aortic arch was left innominate artery(abbreviations LSCA left subclavian artery, LCCA left common carotic artery, RCCA right common carotid artery, LCA left coronary artery). Fig. 7B. Right anterior oblique view of aortogram in the same baby through the right brachial artery clearly demonstrated aortic interruption proximal to the origin of right subclavian artery. Descending aorta is opacified as well as PDA and both PA s(abbreviations RSCA right subclavian artery, PA pulmonary artery, DAO descending aorta). 내에서 조영제가 혈관 밖으로 새어나간 경우는 한 예 도 없었다. 서는 합병증이 전혀 없었고 사용하였던 동맥을 통한 고 혈류와 손의 말초관류도 정상이었다. 안 동맥, 도관, 주사기, 주사하는 의사의 손이 전부 일 직선상에 있지 않았을 경우에는 주사시에 조영제가 심초음파 진단법의 획기적인 발전으로 인해 일부분 환자의 몸밖으로 튀는 경우가 간혹 있었으나 환자 체 의 선천성 심질환에서 침습적인 심도자 및 심혈관 조 844

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8 요약 연구배경 : 방법 : 결과 : 846

9 결론 : References 1) Stark J, Smallhorn JF, Huhta J, de Leval A, MaCartney FJ, Rees PG, Taylor JFN:Surgery for congenital hear defects diagnosed with cross-sectional echocardiography. Circulation 68(suppl 2): , ) Gibbs JL:Ultasound and coarctation of the aorta. Br Heart J 641: , ) Castellanos A, Pereiras R:Counter-current aortography. Rev Cubana Cardiol 2: , ) Keith JD, Forsyth C:Aortography in infants. Circulation 2: , ) Singleton EB, McNamara DG, Colley DA:Retrograde aortography in the diagnosis of congential heart disease in infants. J Pediatrics 47: , ) Ueda K, Satio A, Nakano H:Aortogoraphy by countercurrent injection via the radial artery in infants with congenital heart disease. Pediatr Cardiol 2: , ) Patres PR, Feldman CJ, Vitola D, Perez AJ, Genro CH, Kalil KA, Falleiro R, Lucches FA, Nesralla LA, Rodruigues R : Counter-current asortography by contrast injection into a pediphred artery. Arch Inst Cardiol Mex 58(1):27-29, ) Lau KC, Lo RNS, Leung MP:Axillary artery countercurrent aortography in the newborn with aortic arch obstruction. Pediater Radiol 19: , ) Anjos R, Kakadekar A, Murdoch I, Baker E, Ty nan M, Quresh S:Countercurrent aortography:an alternative to cardiac catheterization inflancy. Pediatr Cardiol 13: 10-13, ) Carvalho JS, Rodington AN, Shinebourne EA, Righy ML, Gibson D:Continuous wave Doppler echocardiogrphy and coarctation of the artaz:gradients and flow patterns in the assessment of severity. Br He-art J 64: , ) Houston AB, Simpson IA, Polock JCS, Jamieon MPG, Doig WB, Coleman EN:Dopperultltrasoun dht eassessment of severity of coarction of the arta and interruption of the acortc arch. J 57:38-43, ) WilSon N, Sutherland GR, Gibbs JL, Dickinsion DF, Keeton B:Limitatios of Doppler ultrasound in the diagnosis of neonatal coarcation of the aorta. Int J Cardiol 23:87-89, ) American Heart Association : Textbook of pediatric avanced life support;in Chameides L(Ed):Dallas, American Heart Assocatio, 1988, p ) Down JB, Rackstein AD, Klein EF, Hawkins EF:Hazards of radial-artery catheterization. Anesthesiology 38: , ) Wyatt R, Glaves I, Cooper DJ:Proximal skin necrosi after radial-artery cannulation. Lancet 1: , ) Lowenstein E, Little JW, Lo HH:Prevention of cerebral embolization from flushing radial artery cannulas. N Engl J Med 258: , ) Adams JM, Rudolph AJ:The use of indwelling radial artery catheters in neonate. Pediatrics 55: ,

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding