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1 Original ORIGINAL Article ARTICLE Korean Circulation J 005;35: ISSN c 005, The Korean Society of Circulation 복부대동맥류에서인조혈관스텐트 (Stent-Graft) 를이용한경관적치료의단기및중기임상결과 연세대학교의과대학심장혈관병원심장내과학교실, 1 진단방사선과학교실, 흉부외과학교실 3 김병극 1 박성하 1 고영국 1 정보영 1 최동훈 1 장양수 1 이도연 장병철 3 심원흠 1 Immediate and Mid-Term Outcomes of the Endovascular Stent-Graft Treatment of Abdominal Aortic Aneurysm Byoung-Keuk Kim, MD 1, Sungha Park, MD 1, Young-Guk Ko, MD 1, Boyoung Joung, MD 1, Donghoon Choi, MD 1, Yangsoo Jang, MD 1, Do-Youn Lee, MD, Byoung-Chul Chang, MD 3 and Won-Heum Shim, MD 1 1 Cardiovascular Division, Department of Diagnostic Radiology and 3 Cardiovascular Surgery, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea ABSTRACT Background and Objectives:Although the standard management of an abdominal aortic aneurysm (AAA) is surgery, endovascular stent-graft treatment is more attractive for patients with significant co-morbid conditions. We evaluated the immediate and mid-term outcomes for the endovascular treatment of AAA. Subjects and Methods:Between November 1996 and August 004, 59 patients with an AAA (53 males, mean age 68.0±9.6 years, 3 cases with ruptured AAA) underwent an endovascular stent-graft repair at our institute. All patients were evaluated by an angiography, taken just after the completion of the procedure and at followed up with computed tomography (CT) at 1, 3, 6 and 1 months, and yearly thereafter. Results:Technical success was achieved in 54 of the 59 patients (91.5%). The periprocedural mortality rate was 3.4% ( of the 59 patients). A primary endoleak was found in 1 patients (0.3%)(type I; 9 patients, type II; patients, type III; 1 patient), of which required subsequent surgical conversion. Spontaneous resolution of an endoleak was seen in 4 patients (33.3%). The average follow-up period of 57 patients was 7.5 months (range from 7 days to 581 days). In 8 patients (14.0%), a newly developed secondary endoleak was documented. A total 14 patients (3.7%) died during the follow-up period (rupture; 3, operation-related sepsis; 3, unrelated causes; 3, cardiac arrest; 1, unknown causes; 4). The cumulative survival rates at 30 days and at 1 and years were found to be 93.0, and 85.7 and 76.3%, respectively, using Kaplan-Meier methods. Secondary intervention was required in 1 patients (1.8%), and surgical conversion in 4 (6.8%), with (3.4%) requiring conversion to open surgery immediately after the intervention. In those with technical success, without endoleaks and graft failure, the survival rate during follow-up was higher (97.1%; rate with the exception of unrelated cause of death) than that of all the patients. Conclusion:The immediate and mid-term results suggest that the endovascular treatment of an AAA is technically feasible and effective. There was higher mortality and morbidity in primary and newly developed endoleak cases; therefore, proper selection of cases, according to the anatomical and clinical criteria, is essential, with meticulous regular follow-ups being critical for the optimal endovascular treatment of an AAA. (Korean Circulation J 005;35: ) KEY WORDS:Aortic aneurysm, abdominal;stent, grafts;treatment outcome. 논문접수일 :005 년 3 월 8 일심사완료일 :005 년 6 월 13 일교신저자 : 심원흠, 서울서대문구신촌동 134 연세대학교의과대학심장혈관병원심장내과학교실전화 :(0) 전송 :(0) whshim@yumc.yonsei.ac.kr 583

2 584 Korean Circulation J 005;35: 서 복부대동맥류는매우치명적인임상경과를가지는질환으로서적절한치료를하지않을경우대동맥류파열에의한사망률이 90% 이상으로보고되고있다. 1) 현재까지는수술적치료, 특히계획적 (elective) 수술이가장효과적으로대동맥류파열을예방하는방법으로알려져있다. )3) 그러나, 대동맥류환자들의대부분이고령이고동맥경화로나타나는심혈관및뇌혈관질환과신기능의이상등의질환이많이동반되어수술을위한전신마취의금기증이되는경우가있어수술적치료자체가힘든경우가많다. 또한수술적치료로인하여회복기간및입원일수가길어지고수술후수술과연관된사망률이높아서일부환자군에선많은제한점을안고있는치료이다. 4) 이런관점에서인조혈관스텐트 (stent-graft) 를이용한경관적 (endovascular) 치료법은수술적치료에비해덜침습적이며전신마취가필요없어시술후 1~ 일후보행이가능할정도로회복이빠른것이장점이다. 5-8) 그러나, 이런경관적치료법의중, 장기임상결과는기관에따라상이하게발표되고있다. 4)9-13) 이에본연구는인조혈관스텐트를이용하여경관적치료를받은복부대동맥류환자들의단기및중기임상결과에대해알아보고자하였다. 론 대상및방법 대상환자는 1996년 11월부터 004 년 8월까지복부대동맥류로진단받고본원에서인조혈관스텐트삽입술을시행받은 59명의환자들로하였다. 모든환자에서시술전관동맥조영술과말초혈관조영술을시행하여관동맥및말초혈관협착증의동반여부를알아보았고, 동반질환의유무도조사하였다. 환자의추적관찰은시술후 1, 3, 6, 1개월째에임상적평가및복부전산화단층촬영을시행하였고그이후로는매년시행하였다. 인조혈관스텐트삽입술의대상환자는복부대동맥류의최대직경이 6 cm 이상이거나, 직경이 5 cm 이면서이전 6개월동안 0.5 cm 이상크기가증가하는경우로하였고, 신장동맥기시부와대동맥류기시부까지의간격 (length of proximal neck) 이 15 mm 이하이거나 proximal neck 의굴곡도 (angulation) 가 60도이상인경우, 장골동맥을인조혈관스텐트로완전하게봉쇄하기불가능한경우, 장골동맥이 90도이상으로너무구부러진경우, 그리고원형석회화가심한경우등은대상환자에서제외하였다. 본연구에서는다양한제품의인조혈관스텐트가사용되었는데 Vangard (Boston Scientific, Inc., Oakland, NJ) 3예, AneuRx (Medtronic, Inc., Minneapolis, MN) 13예, Zenith (Cook, Inc., Bloomington, Indiana) 예, Excluder (W. L. Gore and Associates, Flagstaff, AZ) 예였고, 나 머지 19예는크기에맞춰국내에서특수생산된인조혈관스텐트를이용하였다. 스텐트는모두분지형으로, 대동맥과총장골동맥을이어주는본체부분 (main body) 과반대쪽총장골동맥에삽입되는가지부분 (limb) 으로두부분으로이뤄진형태였다. 시술은심도자실에서경막외또는국소마취하에서시행되었고, 환자의대퇴동맥에 16Fr 에서 Fr 의피포 (sheath) 를삽입하였다. 스텐트의상부는동맥류확장을막기위해가장하단에위치한신동맥에근접하여위치시켰고필요한경우대동맥과장골동맥에연장편 (extenders) 이추가되었다. 시술후모든환자에서바로하대동맥조영술을시행하여혈류누출 (endoleak) 여부를확인하였다. 용어의정의기술적성공 (technical success) 은수술로의전환필요성이없이기구가확장 (deployment) 이되어시술을마치는것으로하였다. 합병증은 SCVIR(Society of Cardiovascular & Interventional Radiology) 표준과 14) Zarins 등 15) 의경증 (minor), 중증 (major) 합병증의분류를따랐는데, 경증합병증은단순한혈관내시술방법으로해결되며심각한문제가아닌경우로하였고중증합병증은분리된시술이나추가절개에의한시술이요구되는경우혹은사망, 심근경색, 혹은수술등의심각한문제가발생하는경우로하였다. 인조혈관스텐트시술후발생하는혈류누출은 White 등 16) 이제창한분류에따라 4가지형태로나누었다 (Fig. 1). 또한, 추적검사결과스텐트의구조적인결함 [ 골절 (fracture), 찌그러짐 (kinking), 이식편의분리 (separation)], 스텐트의이동 (migration) 및스텐트내혈전이형성되어혈류의흐름이차단되는경우등을스텐트부전 (graft failure) 으로정의하였다. 추적관찰중혈류누출, 스텐트부전등의이유로인조혈관스텐트가삽입되어있는상태에서추가적인시술이나수술적치료가필요했던경우를이차적시술 (secondary intervention) 으로정의하였다. 기술적으로성공한후혈류누출, 인조혈관스텐트부전및중증합병증의객관적인증거가없고추가시술이나수술의필요성없는무사건생존은완전한임상적성공 (clinical success) 로정의하였다. 임상적결과는 48시간이내와 30일의단기성적과평균관찰기간 7개월의중기임상성적을알아보았다. 결 대상환자의특성전체대상환자 59명중남자는 53명 (89.8%) 이었고, 평균연령은 68.0±9.6 세이었다. 동반질환을보면고혈압을가진환자는 40명 (67.8%), 관동맥협착질환은 7명 (45.8%), 만성신부전은 5명 (8.5%) 에서관찰되었다. 시술전복부전산화단층촬영상평균대동맥류직경은 6.0±1.3 cm(4.7~ 과

Byoung-Keuk Kim, et al:stent-graft Treatment of AAA 585 Type I endoleak, proximal Type III endoleak Type I endoleak, distal A Type II endoleak, according to collateral vessel B Fig. 1.

Type III: mid-graft leak due to device defect. Table 1.

3 Byoung-Keuk Kim, et al:stent-graft Treatment of AAA 585 Type I endoleak, proximal Type III endoleak Type I endoleak, distal A Type II endoleak, according to collateral vessel B Fig. 1. Types of endoleaks. Type I: attachment endoleak, proximal or distal stent-graft portion. Type II: branch flow leak from lumbar, inferior mesenteric, hypogastric, renal or other arteries. Type III: mid-graft leak due to device defect. Table 1. Clinical and radiological characteristics of 59 patients with abdominal aortic aneurysm treated with endoluminal stent-graft Characteristics Value % Age Mean±SD 68±9.6 Range Sex Male Female Associated diseases Hypertension Diabetes Coronary artery disease Chronic renal failure Congestive heart failure Diameter of aneurysm, cm±sd (range) 6.0±1.3 ( ) Ruptured AAA SD: standard deviation, AAA: abdominal aortic aneurysm 8.7 cm) 이였고, 전신상태가불량하여수술적치료가불가능했던파열된복부대동맥류 (ruptured AAA) 에서의인조혈관스텐트삽입술은 3명 (5.0%) 의환자에서시행되었다 (Table 1). 초기결과전체 59명의환자중 54예 (91.5%) 에서완전한기구확장 (deployment) 이가능한기술적성공이이뤄졌고, 5예에서시술이실패하였는데, 장골동맥의굴곡이심하여인조혈관스텐트가병소까지이동할수없었던경우가 1예, 총장골동맥의혈전증으로이동이불가능했던경우가 1예, 그리고풍선확장술시행도중스텐트이식편이분리되어버린경우가 3예있었다 (Table ). 시술 48시간내사망은 예 (3.4%) 에서관찰되었는데, 1예는성공적인시술후 1일째갑작스런심정지로사망하였는데환자는관동맥협착증 ( 세혈관협 Table. Early results and immediate complications in a group of 59 patients with AAA treated by the endovascular stent-graft implantation No. of patients (%) Early results Technical success 54 (91.5) Technical failure 5 (08.5) Iliac artery tortuosity 1 Thrombosis of common iliac artery 1 Disruption of connection part 3 Periprocedural mortality (<48 hours) (03.4) Rupture 1 Cardiac arrest 1 Primary endoleak 1 (0.3) Type I endoleak 9 (75.0) Type II endoleak Type III endoleak 1 Immediate complications 9(15.3) Minor complication 5 Arteriovenous fistula 1 Hematoma Hemorrhage Major complication 4 Cardiac arrest Immediate operation conversion AAA: abdominal aortic aneurysm 착 ) 으로스텐트삽입술시행받은과거력을가지고있었다. 또다른환자는파열된대동맥류로응급경관적시술을시행받은환자로, 시술직후대동맥조영술상 1형혈류누출이여전히지속되었고시술다음날대동맥류파열악화로심정지발생하여사망하였다. 시술직후시행한대동맥조영술이나복부전산화단층촬영에서혈류누출은 1 예 (0.3%) 에서관찰되었고, 1형이 9예로가장많았다. 시술직후발생한합병증을보면중증 (major) 합병증은

4 586 Korean Circulation J 005;35: 시술 48시간내사망한 예를포함하여 4예 (6.8%) 에서발생하였다 (Table ). 경증 (minor) 합병증은 5예 (8.5%) 에서발생하였고, 내부장기의허혈이나괴사및색전증은관찰되지않았고응급투석을필요로하는급성신부전의발생도없었다 (Table ). 추적관찰의결과추적관찰은 57명 (96.6%) 에서가능하였고, 평균추적관찰기간은 7.5±4.6 개월이었다. 시술후 30일이내에혈류누출, 스텐트부전및주요합병증이전혀없는 30일째임상적성공률 (clinical success at 30 days) 은 87.7% 였고, 30일사망률은 7.0% 였다. 사망의원인은 Table 3과같았고여기에는정신과적인문제로자살한환자의 1예도포함되었다. Table 3. Follow-up results No. of patients (%) Total number of patients, followed up 57 (96.6) Follow-up duration±sd, months 7.5±4.6 Clinical success at 30 days 50 (87.7) 30-day mortality 4 (07.0) Rupture 1 Operation-related sepsis 1 Cardiac arrest 1 Suicide 1 AAA sac size on follow-up CT 53* Decreased or no change 47 (88.7) Increased 6 (11.3) Graft failure 6 (10.5) Stent thrombosis Stent fracture and separation Stent migration Secondary endoleak 8 (14.0) Secondary intervention 1 (1.8) Embolization 5 Additional stent-graft Open repair 1 Bypass surgery due to stent-graft thrombosis 4 Conversion to open repair 4 (06.8) Early surgical conversion Late surgical conversion* Late cause of death after 30 days 10 (17.5) Rupture Operation-related sepsis Unrelated causes (cancer, traffic accident) Unknown causes 4 Cumulative 1-year survival rate 85.7% Cumulative -year survival rate 76.3% *: late surgical conversion was occurred 1 year after stent-graft implantation. : survival rate was analyzed by Kaplan-Meier methods. SD: standard deviation, AAA: abdominal aortic aneurysm, CT: computed tomography 추적관찰기간동안시행한복부전산화단층촬영에서대동맥류의크기가커진경우는 6예 (11.3%) 에서관찰되었다. 인조혈관스텐트의부전 (graft failure) 은 6예 (10.5%) 에서관찰되었고, 추적관찰도중새로생긴 차혈류누출 (secondary endoleak) 은 8명 (14.0%) 에서있었다. 혈류누출및스텐트부전증등의이유로이차적인시술이나수술적치료가필요했던경우 (seconadary intervention) 는 1 예 (1.8%) 에서있었다. 총추적관찰기간동안수술적전환은 4예 (6.8%) 에서시행되었고, 그중 예는입원기간중수술적치료로전환되었고나머지 예는추적관찰 1년이후에시행되었다 (Table 3). A Type I endoleak 9 (75.0%) B Surgery Resolution; Glue embolization; 1 Operation conversion; death (Op. sepsis) Additional stent-graft; 1 death (unknown) Stent thrombosis Primary endoleak 1 (0.3%) Type II endoleak (16.7%) Death; (Rupture 1, Refuse treatment) Embolization 3 Incomplete results, but treatment refused Death; 1 C Resolution; Stent-graft failure 6 (10.5%) Stent fracture and Separation Surgery Resolution; Secondary endoleak 8 (14.0%) Additional stent 3 Resolution; 1 Persist endoleak coil embolization; 1 Persist endoleak Operation conversion Death due to sepsis; 1 *1 Death due to operation-related sepsis Type III endoleak 1 (8.3%) Operation conversion; 1 Observation Resolution; 1 Treatment refuse Death; 1 Stent migration Surgery 1 Fig.. Treatment of endoleaks and graft failure. A: treatment and fate of primary endoleak according to sub-types. B: newly developed secondary endoleak and its treatment. C: graft failure during followup and its causes and treatment.

Byoung-Keuk Kim, et al:stent-graft Treatment of AAA 587 시술 30일이후사망한환자는 10명 (17.5%) 이었고, 대동맥류파열이 예, 수술과연관된패혈증이 예, 대동맥류와연관이없는이유로사망한환자가 예 ( 교통사고 1예, 진행성위암 1예 ), 사망의원인이뚜렷하지않은경우가 4예였다.

3%) 에서관찰되었고, 특히 형혈류누출은모두추적관찰중에자연히소실되는소견을보였다. 색전술은 1예, 수술적치료로의전환은 3예 (1형 ; 예, 3형 ; 1예 ), 추가적인인조혈관스텐트삽입은 예에서시행하였고, 나머지 명중 1명은치료를거부하였고 1명은관찰중대동맥류파열로사망하였다.

5 Byoung-Keuk Kim, et al:stent-graft Treatment of AAA 587 시술 30일이후사망한환자는 10명 (17.5%) 이었고, 대동맥류파열이 예, 수술과연관된패혈증이 예, 대동맥류와연관이없는이유로사망한환자가 예 ( 교통사고 1예, 진행성위암 1예 ), 사망의원인이뚜렷하지않은경우가 4예였다. Kaplan-Meier 생존분석결과누적 1년생존율이 85.7%, 년생존율이 76.3% 였다. 혈류누출및스텐트부전 (Graft failure) 의치료시술후생긴초기혈류누출 (primary endoleak) 의치료를보면 (Fig. A), 추적관찰중자연소실된경우는초기혈류누출을보인 1예중에서 4예 (33.3%) 에서관찰되었고, 특히 형혈류누출은모두추적관찰중에자연히소실되는소견을보였다. 색전술은 1예, 수술적치료로의전환은 3예 (1형 ; 예, 3형 ; 1예 ), 추가적인인조혈관스텐트삽입은 예에서시행하였고, 나머지 명중 1명은치료를거부하였고 1명은관찰중대동맥류파열로사망하였다. 새로이발생된 차혈류누출 (secondary endoleak) 의치료는전체 8명의환자중에서색전술은 3예, 추가스테트삽입이 3예에서시행되었고, 명의환자에선다른치료없이관찰하기로하였다 (Fig. B). 스텐트부전의치료는 4예에서수술적치료가필요하였다 (Fig. C). 혈류누출과스텐트부전의치료와관련하여적절한치료가있었으나모든추가적인치료형태를거부한환자는 3명이었고이들은모두추적관찰중에사망하였다. 추적기간중전체사건및사망환자의정리추적기간중전체사건및사망환자들을따로정리해보면 (Fig. 3), 시술시기술적으로실패한 (technical failure) 환자가 5명이었고그중 4명에서초기혈류누출이관찰되었다. 초기혈류누출은총 1명 (0.3%) 에서관찰되었고, 이들중 6명이추적기간동안에사망하여혈류누출을보인환자의사망률은 50% 였다. 차혈류누출을보인환자 의사망률은 37.5% 였고 (8 명중 3명사망 ), 스텐트부전을보인환자의사망률은 16.7%(4 명중 1명사망 ) 였다. 총추적기간동안기술적실패, 혈류누출및스텐트부전없고사망하지않는무사건생존율, 즉완전한임상적성공 (clinical success) 은 5.6% 정도였다 (Fig. 3A). 기술적으로성공하고혈류누출및스텐트부전을보이지않은환자는 34명 (60.0%) 이었고이들중사망한환자는 4 명으로사망률은 11.8% 였다 (Fig. 3B). 사망한 4명의사망원인을보면, 한명은복부전산화단층촬영상혈류누출이나대동맥류크기의증가없이잘지내다가시술 310 일째진행성위암으로사망하였고, 또다른한명도시술후검사상다른이상소견없이잘지내다가 66 일째교통사고로사망하였고, 또다른한명의환자는사망의원인은뚜렷하지않았는데사망당시나이가 85세였고, 과거력상심한관동맥협착증을가졌고말기신부전증으로투석을하던분이었다. 이렇게초기시술의기술적성공과함께혈류누출을보이지않은환자중에서대동맥류와연관된사망이아닌환자들을빼면총추적관찰기간사망률이.9% 였다. 고 복부대동맥류의경관적치료법은 1990 년 Parodi 등 17) 에의해처음으로시행된이래로대동맥류치료의한방법으로자리잡기시작하였다. 많은연구들에서경관적인조혈관스텐트삽입술이이전의일반적인개복수술적치료에견줄만한높은초기성적과안전성을보였다고발표되었다. 7)15)18)19) 초기임상적결과를보면, 중환자실치료기간및전체입원일수를의미있게감소시켰고, 출혈이나주요합병증을크게줄일수있고, 또한회복이빠르다는장점으로고령및중증의심각한동반질환을갖는환자들에서수술적치료를대체할수있는치료로부상하였다. 그러나인조혈관스텐트삽입술의중, 장기임상적결과에대해선조 찰 No of total death Technical failure ; 14 5/59 (8.5%) 4 8 Primary endoleak 1/59 (0.3%) 8 Secondary endoleak 8/57 (14.0%) 4 Graft failure 6/57 (10.5%) Clinical success during overall follow-up; 30/57 (5.6%) A Technical success 54/59 (91.5%) - follow-up loss; - Primary endoleak - Secondary endoleak - Graft failure Total number of technical success without leak & failure 34 patients ; 4 pts died but, - patients died due to unrelated causes (Stomach cancer, traffic accident) - 1 patients died due to unknown causes, but he was 85-year-old (Coronary artery disesa (3 vessel disease), End-stage renal disease) Significant death in clinical success ; 1/34 (.9%) If no endoleak & graft-failure, nearly no events! B Fig. 3. Summary of all events (A) and characteristics of clinical success without events (B). A: all cause events and its associated mortality during follow-up. Clinical success rate without any events was 5.6%. B: fate of technical success without endoleak and graft-failure. If there is no endoleak and graft-failure after procedure, we can expect the decrease of mortality rate.

6 588 Korean Circulation J 005;35: 금상이한결과들이보고되고있는데, 일부연구들에선이런경관적치료의우수한초기성적이 3~6 년이경과한후에도유지된다고보고하였지만, 0)1) 다른연구들에선인조혈관스텐트의내구성에대한문제를제기하였고, 후기에재시술및수술로의전환율이높아궁극적으로는파열의확률이높아질수있다는문제를제기하였다. 9-13) 현재까지는경관적치료와수술적치료의전향적무작위분석에의한후기임상적결과에관한비교연구는없었고다만최근에전신마취에의한수술적치료가가능한환자들을대상으로경관적치료와수술적치료의무작위전향적분석을시행한 EVAR(endovascular aneurysm repair) 1 trial ) 의 30일사망률이보고되었는데, 경관적치료의사망률이수술보다의미있게낮았으나추가적인 차시술의비율은경관적치료가더높다고보고하였다. 이렇듯이아직까지는경관적시술치료의표준화된성적이나오지않는상태에서본원에서도 96년부터수술의고위험군환자인고령및중증의동반질환을가진환자들을중심으로경관적인조혈관스텐트삽입술을시행하여수술적치료에비견할만한효과적인높은단기임상적결과를보고하였고, 19)3) 이후추가로시술받은환자들을포함하여이들전체의단기및중, 장기임상적결과를알아보고자하였다. 본연구에서의결과를보면, 시술전후사망률은 3.4%, 주요합병증의병발율은 6.8% 였고, 30일사망률 (30-day mortality rate) 은 7.0% 였다. 이는다른연구들의결과들과 4)5)11)13)4) 거의유사한범주에들어가는결과였다. 비교적동반질환의심각성이덜하고전신마취가가능했던환자들을대상으로하는수술적치료와비교시에도 1-3)4)11) 유사한초기사망률을보였고, 일부연구들보다는더낮은시술후합병증을보였다. 중, 장기생존율을보면, 1년누적생존율 (cumulative survival rate) 이 85.7% 였고 년누적생존율이 76.3% 였다. 다른연구의결과들을비교해보면 Zarins 등 1) 은 AneuRx stent-graft 를이용하여 년생존율 88%, 3년생존율을 86% 로보고하였고, Clouse 등 4) 은 년생존율을 78.4% 로보고하였고, EUROSTAR 코호트의결과를보면 11) 4년생존율을 75% 로보고하는등대상환자의상이한위험인자들에따라서조금씩다른결과를보고하고있다. 본원의생존율은다른연구들과비슷하거나조금낮은생존율을보이는데이는첫째, 치료대상군이비교적고령의고위험군의환자들이고, 둘째, 파열된대동맥류 (ruptured AAA) 환자들이 3명포함되었는데, 이들중 명이입원기간중조기사망하였고, 셋째, 대동맥류인조혈관스텐트삽입술초기의환자들이스텐트재질및시술초기의경험부족으로인한혈류누출및그에따른병의악화로사망한환자들이일부포함되어생존율이조금더낮을것으로생각되었고, 네번째이유는한국의고령환자들의치료행태와관련된것으로, 전체사망한 14명의환자중에서가능한추가적인시술이나수술등의방법이있는 데도치료권고를모두거부하고사망한환자가 3명 (1.4%) 이포함되어 (Fig. ) 더낮은생존율을보인것으로생각되었다. 복부대동맥류의경관적치료에있어서초기혈류누출과 차혈류누출의출현및이에따른 차적시술이나수술적전환의필요성이가장문제가되고있고, 또한후기의스텐트부전 (graft failure) 이나다른특별한원인없이대동맥류파열이일어날수있는후기내구성의불안정성문제도발표되고있다. 9-13) 본연구에서초기혈류누출및 차혈류누출은각각 0.3% 와 14.0% 였다. 이는다른연구의결과와도유사한범주였고 5) 이들환자중 형혈류누출은대부분치료없이추적관찰중자연적으로소실되었으나 1 형의경우추적관찰동안에색전술, 추가인조혈관스텐트삽입및수술적치료로의전환율이높았고또한다른환자들보다높은사망률을보였다. 스텐트부전은 10% 에서관찰되었으나대부분 차적시술에의해잘조절되는양상을보였다. 결국본연구에서도초기혈류누출이적절하게치료되지않았거나추적관찰중, 후기에새롭게혈류누출이발생하면이와관련하여사망률이높아지는경향을관찰할수있었다. 본연구에서의전체사건및사망환자의정리하여분석한결과를보면 (Fig. 3), 시술을성공적으로끝내고혈류누출이나스텐트부전을보이지않은환자의경우대동맥류와무관하게사망한환자를제외하면실질적인사망률은.7% 로전체대상환자의사망률보다매우낮은수치를보였다. 즉시술을성공적으로끝내고이후혈류누출을막을수있으면이후추적관찰에서사건, 사망률을의미있게줄여무사건률및생존율을크게향상시킬수있을것이라는사실을알수있다. 혈류누출에관한연구들을보면 6) 1형혈류누출에영향을주는인자로 proximal neck 직경의석회화범위 (percentage of calcified neck circumference), 대동맥류최대직경, proximal neck 의길이와이에따라겹쳐지게되는인조혈관스텐트부분의길이 (proximal neck and device overlap), 대동맥류의굴곡도 (angulation) 등이있는데초기에검사상대동맥류의크기가크면서대동맥류의 proximal neck 의길이가짧고석회화가심한환자는혈류누출의위험이매우큰고위험군으로서이때는보다신중한치료형태가고려되어야할것이다. 이상의본연구결과를보면인조혈관스텐트를이용한경관적치료는고위험군환자들을대상으로높은성공률로시행될수있는안전한치료이며, 수술적치료에비견할만한단기및중기임상적결과를보였다. 그러나추적관찰중, 후기에사망률이증가할수있으므로복부전산화단층촬영을포함한규칙적인추적관찰이꼭필요하고이결과에따라서혈류누출이나다른이상을막는철저한 차적시술이고려되어야할것같다. 또한이들환자군의추가적인후기관찰을통해서장기임상적결과에대한평가도

7 Byoung-Keuk Kim, et al:stent-graft Treatment of AAA 589 향후에지속적으로시행되어야할것이다. 이번연구를통해초기혈류누출이없이시술을성공적으로끝낸환자들의임상적결과가우수하므로환자선정에있어서의보다철저한기준이고려되어야할것으로생각되고, 향후이런혈류누출에영향을주는고위험인자를중심으로한전향적인연구가필요할것이다. 요약 배경및목적 : 복부대동맥류의기본적인치료법은수술적치료지만, 고령의심각한동반질환을가진환자들에있어서는경관적치료가보다효과적일수있을것이다. 이에인조혈관스텐트를이용하여경관적치료를받은복부대동맥류환자들의단기및중기임상결과에대해알아보고자하였다. 방법 : 1996년 11월부터 004 년 6월까지복부대동맥류로진단받고본원에서인조혈관스텐트삽입술을시행받은 59 명의환자들을대상으로하였다. 대상환자중남자는 53명 (89.8%) 이었고, 평균연령은 68.0±9.6 세였고, 파열된복부대동맥류 (ruptured AAA) 에서의인조혈관스텐트삽입술이 3명 (5.0%) 의환자에서시행되었다. 모든환자에서시술전복부전산화단층촬영및혈관조영술을시행하였고, 기술적성공여부확인을위해시술직후혈관조영술을시행하였다. 이후시술후 1, 3, 6, 1개월째임상적평가와함께추적복부전산화단층촬영을시행하였고그이후는매년전산화단층촬영을시행하였다. 결과 : 전체 59 명중 54 명 (91.5%) 에서기술적성공이이뤄졌고, 시술관련사망률은 3.4% 였다. 초기혈류누출은 1 명 (0.3%) 의환자에서관찰되었고 (I형 ; 9명, Ⅱ형 ; 명, Ⅲ형 ; 1명 ) 이중에서 4명 (33.3%) 의환자에선자연적으로혈류누출이소실되었고, 명은수술적전환이필요했다. 추적관찰은 57 명에서가능했고, 평균추적관찰기간은 7.5±4.6 개월이었다. 8명 (14.0%) 의환자에서새로보이는 차혈류누출이관찰되었다. 추적관찰기간동안사망한총환자는 14 명 (3.7%) 이었다 ( 대동맥질환과전혀무관한사망 ; 3명, 대동맥류파열 ; 3명, 수술관련패혈증 ; 3명, 갑작스런심장마비 ; 1명, 원인미상 ; 4명 ). Kaplan-Meier 생존분석에의한 30일, 1년, 및 년누적생존율이각각 93.0%, 85.7%, 76.3% 였다. 차적시술은 1명 (1.8%), 수술적전환은 4명 (6.8%) 에서이뤄졌다. 그중 명은시술직후바로수술을시행받았다. 시술을성공적으로끝내고혈류누출이나스텐트부전을보이지않은환자의실질적인사망률은.7% 였다. 결론 : 복부대동맥류의경관적치료법은고위험군환자들을대 상으로높은성공률로안전하게시행될수있는치료법이며, 수술적치료에비견할만한단기및중, 장기임상적결과도보였다. 그러나추적관찰중, 후기에사망률이증가할수있으므로복부전산화단층촬영을포함한규칙적인추적관찰이꼭필요하고, 또한초기혈류누출이없이시술을성공적으로끝낸환자들의임상적결과가더욱우수하므로초기환자선정에있어서의보다철저한기준이필요할것이다. 중심단어 : 복부대동맥류 ; 인조혈관스텐트 ; 임상결과. REFERENCES 1) Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;38: ) Hallin A, Bergqvist D, Holmberg L. Literature review of surgical management of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 001;: ) van der Vliet JA, Boll AP. Abdominal aortic aneurysm. Lancet 1997;349: ) Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysm: report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 003;37: ) Blum U, Voshage G, Lammer J, et al. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336: ) Cuypers P, Buth J, Harris PL, Gevers E, Lahey R. Realistic expectations for patients with stent-graft treatment of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1999;17: ) Matsumura JS, Brewster DC, Makaroun MS, Naftel DC. A multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 003; 37: ) Rinckenbach S, Hassani O, Thaveau F, et al. Current outcome of elective open repair for infrarenal abdominal aortic aneurysm. Ann Vasc Surg 004;18: ) Beebe HG, Cronenwett JL, Katzen BT, Bewster DC, Green RM. Results of an aortic endograft trial: impact of device failure beyond 1 months. J Vasc Surg 001;33:S ) Holzenbein TJ, Kretschmer G, Thurnher S, et al. Midterm durability of abdominal aortic aneurysm endograft repair: a word of caution. J Vasc Surg 001;33:S ) Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, Laheij RJ. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 000;3: ) Bernhard VM, Mitchell RS, Matsumura JS, et al. Ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Surg 00;35: ) Gorham TJ, Taylor J, Raptis S. Endovascular treatment of abdominal aortic aneurysm. Br J Surg 004;91: ) Patel N, Sacks D, Patel RI, et al. SCVIR reporting standards for the treatment of acute limb ischemia with use of transluminal removal of arterial thrombus. J Vasc Interv Radiol 001;1: ) Zarins CK, White RA, Schwarten D, et al. AneuRx stent graft versus open surgical repair of abdominal aortic aneurysm: multicenter prospective clinical trial. J Vasc Surg 1999;9:9-305.

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12.ÀÇÇÐ°�ÁÂc10«±âÃµ-42~552

12.ÀÇÇÐ°�ÁÂc10«±âÃµ-42~552 Endovascular Aneurysm Repair Kee Chun Hong, M.D. Jang Yong Kim, M.D. Yong Sun Jeon M.D. Department of Surgery Radiology* Inha University College of Medicine & Hospital E mail : keechong@inha.ac.kr Abstract