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1 대한혈관외과학회지 : 제 24 권제 1 호 Vol. 24, No. 1, May, 2008 대동맥 - 장골동맥폐색증수술결과에유출동맥이미치는영향 울산대학교의과대학외과학교실서울아산병원혈관외과 김향경ㆍ조용필ㆍ문기명ㆍ권태원 The Relation between Distal Runoff and Clinical Outcome after Aorto-iliac Reconstruction Surgery Hyangkyoung Kim, M.D., Yong-Pil Cho, M.D., Ph.D., Ki-Myung Moon, M.D. and Tae-Won Kwon, M.D., Ph.D. Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Purpose: We sought to evaluate the relationship between distal runoff and long-term graft patency in aorto-iliac occlusive disease. Method: A retrospective review was performed on 192 patients with aorto-iliac occlusive disease who underwent surgery between September 1995 and November Patients who underwent percutaneous angioplasty or stent placement were excluded. Preoperative angiograms were scored according to the SVS/ISVS Ad Hoc Committee guidelines. Result: The mean duration of follow-up was 50 months. Procedure indications consisted of claudication in 68 patients and critical limb ischemia in 124 patients. Procedures included 176 bypasses (50 aorto-iliac/aorto-femoral, 32 ilio-femoral, 46 axillo-femoral, and 48 femoro-femoral) and 16 endarterectomies with patch angioplasty. Overall 5-year patency rate was 84.1%. Higher primary patency was observed when the occlusion score of the superficial femoral artery (SFA) or deep femoral artery (DFA) was lower than 2 (P<0.05). Cox proportional hazard model showed run-off resistance values to be significant determinants of graft patency (p=0.000, Exp(B)=1.236). The group that underwent profundoplasty had significantly better long-term patency (P=0.009). Conclusion: Poor distal runoff score was related to lower primary patency. In patients with aorto-iliac occlusive disease and poor distal outflow, profundoplasty can improve primary patency. Key Words: Aorto-iliac occlusive disease, Runoff score, Graft patency 중심단어 : 대동맥 - 장골동맥폐색증, 유출혈관지수, 이식편개존 서 대동맥-장골동맥폐색성질환에서대동맥-대퇴동맥우회술의 5년개존율은 80% 이상으로보고되어있다 (1). 그러나하부혈관에다부위동맥폐색성질환이있을경우이에대한수술이필요할수있으며, 다부위재건수술을시행할경우개존율은 68 83% 정도로보고되고있다 책임저자 : 권태원, 서울시송파구풍납 2동 우 , 서울아산병원혈관외과 Tel: , Fax: twkwon2@amc.seoul.kr 본내용을 8th International Vascular Endovascular Course에서발표하였음. 론 (2). 이식혈관의개존율을유출혈관의상태로예측할수있는여러방법들에대한연구들이있어왔다 (3-8). Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ISCVS) 에서제안한 runoff scoring system(9) 은유출혈류의상태를객관적으로나타내는방법으로여러연구에서이식혈관의개존율을예측할수있는인자로보고되었다 (6,7). Runoff score는문합부의원위부혈관의폐색정도를 0에서 3까지로나누고, 문합부하방분지들의기여도를 0에서 3까지로나누어평가하여기여도와폐색정도를곱한것을각각더한후기저저항인 1을더하여계산한다. 이와같이계산하면 1에서 10까지의값을구할수있고값이클수록저항이높은것을뜻한다. Blankensteijn 등 (6) 은 runoff score을원위부맥박촉지, 연속파형도플러, pulse volume recording, 초 25

2 26 대한혈관외과학회지 : 제 24 권제 1 호 2008 음파혈류측정, 수술중혈관촬영술등과동시에이용하여어떠한항목이조기이식편폐색과관련이있는지살펴보았을때 runoff score만이이식혈관의개존과관련이있다고보고하였다. 저자들은대동맥-장골동맥폐색성질환이있는환자에서수술전시행한전산화단층혈관촬영술이나혈관조영술을통해계산한총대퇴동맥의runoff score와수술의장기성적과의관계를연구하고자하였다. 또한장골동맥이하부위에혈관폐색이있는경우이에대한혈관재건술을동시에시행하여유출혈류를개선시켰을때혈관재건술의결과를개선시킬수있는지연구해보고자하였다. 대상과방법 1995년 9월부터 2005년 11월까지본원에서대동맥-장골동맥폐색성질환으로수술을받은 192명의환자를대상으로후향적연구를시행하였다. 경피적혈관성형술이나스텐트삽입술을시행한환자는제외하였고대동맥-장골동맥이하부위의폐색성질환에대해혈관재건술을시행한환자의경우이를유입동맥수술과동시에시행한환자를포함하였다. 대퇴동맥-슬와동맥우회술이나심부대퇴동맥성형술을유출동맥재건술로정의하였고, 심부대퇴동맥성형술은 2차내지 3차분지부위까지박리한후내막절제술을시행하고그부위를복재정맥첩포를덧대어봉합하는방법으로시행하였다. 남자환자는 175명, 여자환자는 17명이었고평균나이는 (41 87) 세였다. 관찰기간의중위수는 45.4 ( ) 개월이었다. 당뇨가있는환자는 75 (39.1%) 명, 고혈압이있는환자는 102 (53.1%) 명이었다. 수술의적응증으로는간헐적파행증이있던환자가 68명이었고휴식시통증이나상처가있던경우가 124명이었다. 대동맥-장골동맥의병변을 TransAtlantic Inter-Society Consensus의분류에따라구분하면 B형이 11 (5.7%) 명, C형이 32 (16.7%) 명, D형이 149 (77.6%) 명이었다. 수술은대동맥-장골동맥과대동맥-대퇴동맥우회술이 50예, 장골동맥-대퇴동맥우회술이 32예, 액와동맥-대퇴동맥우회술이 46예, 대퇴동맥-대퇴동맥우회술이 48예, 내막절제술과첩포봉합술이 16예에서있었다. 유출동맥에대하여추가적으로수술한경우가 71예에서있었는데대퇴동맥-슬와동맥우회술이 38예, 심부대퇴동맥성형술이 33예에서시행되었다 (Table 1). 수술전 Runoff score는 SVS/ISVS Ad Hoc Committee(9) 의방법에따라측정하였는데, 전산화단층혈관촬영술이나혈관조영술로측정하였고두가지를모두시행한경우전산화단층혈관촬영술영상을분석하였다. 좁아진정도는전산화단층촬영술의경우혈관단면의외막과외 Table 1. Inflow procedures Procedures Patients (%) Anatomic reconstruction 95 (51.0) Aorto-iliac/Aorto-femoral bypass 50 (26.0) Ilio-femoral bypass 32 (16.6) Iliac endarterectomy 16 (8.3) Extraanatomical reconstruction 94 (49.0) Axillo-femoral bypass 46 (24.0) Femoro-Femoral bypass 48 (25.0) 막까지의거리를잰것을혈관직경으로하였고, 내막과내막까지의거리를재어혈관조영술을시행한경우혈관의정상으로보이는직경을기준으로하여좁아진부위의비로 runoff점수를매겼다. 이후총대퇴동맥에대한표재대퇴동맥과심부대퇴동맥의 runoff score을구한후기여도를곱하고기저저항을더하여 1에서10까지의 runoff score을구한후 runoff score와개존율과의상관관계를구하였다. 또한 0에서 3까지의표재대퇴동맥과심부대퇴동맥의폐색도와개존율과의상관관계를구하였다. 재건혈관의개존여부는의무기록과추적전산화단층촬영술영상을분석하여판단하였다. 전체개존율및 runoff score와개존율과의관계는 SPSS (version 12.0) 프로그램으르이용하여 Kaplan-Meier test로개존율을구하였고 Cox-proportional hazard model을이용하여개존율에영향을미치는인자를분석하였으며 P값 <0.05로유의성을검증하였다. 결 평균발목동맥압지수 (ankle-brachial pressure index, ABI) 는수술전평균 0.31에서수술후평균 0.79로호전되었다. 전체이식편의 5년개존율은 84.1% 였다 (Fig. 1A). 수술의종류별로 5년개존율을구했을때각군간에유의한차이가없었으며해부학적우회술과비해부학적우회술의 5년일차개존율사이에도유의한차이가없었다 (Fig. 1B, C). 총대퇴동맥에서구한 runoff score의평균은 5.2±3.7였고표재대퇴동맥의평균 runoff score는 1.6±1.4이었고심부대퇴동맥의평균runoff score는 1.0±1.2이었다. 단변량분석에서유출동맥의전체 runoff score는일차개존율에유의한관계가있었다 (P=0.001, Odds ratio=1.236). 표재대퇴동맥의 runoff score로회귀분석을시행하였을때 runoff score가높을수록일차개존율이낮았다 (P=0.006). 또한심부대퇴동맥의경우도마찬가지로 runoff score가높을수록일차개존율이낮았다 (P=0.001). 과

3 김향경외 : 대동맥 - 장골동맥폐색증수술결과에유출동맥이미치는영향 27 Fig year primary patency rate. Overall 5 year primary patency rate (A), and 5 year patency rate of groups of different operative methods (B), and 5 year patency rate of anatomical and extraanatomical reconstruction (C). There was no statistically significant difference between groups (P>0.05). Fig. 2. Comparison of primary patency grouped by outflow reconstruction. (A) Femoro-popliteal bypass. (B) Profundaplasty. 유출동맥에대한수술을시행한군과시행하지않은군사이의 runoff score를비교해보았을때대퇴-슬와동맥우회술을시행한군과그렇지않은군의 runoff score 는 7.25±3.11과 4.67±3.63로대퇴-슬와동맥우회술을시행한군에서유의하게 runoff score가높았다 (P=0.001). 그리고심부대퇴동맥성형술을시행한경우의 runoff score 는 8.35±2.37이었고시행하지않은경우는 4.52±3.55로이두군간에도통계적으로유의한차이가있었다 (P=0.000). 그러나유출동맥의병변이없어유출동맥에대한수술이필요없는환자즉 runoff score가 1인환자를제외하였을때대퇴-슬와동맥우회술을시행한군과그렇지않은군의 runoff score는 8.19±2.04와 7.43±2.29였고심부대퇴동맥성형술을시행한경우와그렇지않은군의 runoff score는 8.57±2.00과 7.30±2.23으로유의한차이가없었다 (P>0.05) 대퇴-슬와동맥우회술을시행한군의일차개존율은 1, 3, 5년에각각 99.3%, 96.1%, 86.6% 이었고, 시행하지않은군의일차개존율은 1, 3, 5년에각각 96.7%, 86.7%, 73.7% 로두군사이에유의한차이는없었다 (P>0.05). 심부대퇴동맥성형술을시행한군의일차개존율은 1, 3, 5년에각각 99.3%, 95.3%, 87.3% 이었고, 시행하지않은군의일차개존율은 1, 3, 5년에각각 96.8%, 90.3%, 68.6% 로두군사이에통계적으로유의한차이가있었다 (P <0.05). 유출동맥에병변이없는환자, 즉 runoff score가 1인경우를제외한환자 121 (63.0%) 명에서분석하였을때대퇴-슬와동맥우회술을시행한군의일차개존율은 1, 3, 5년에각각 98.7%, 93.8%, 78.6% 였고, 시행하지않은군의일차개존율은 1, 3, 5년에각각 96.0%, 84.0%, 69.4% 로양군의일차개존율을비교하였을때유의한차이는없었다 (P>0.05, Fig. 2A). 심부대퇴동맥성형술을시행한군의일차개존율은 1, 3, 5년에각각 98.6%, 92.1%, 79.6% 였고시행하지않은군의일차개존율은 1, 3, 5년에각각 97.7%, 90.0%, 66.9% 로두군을비교하여보았을때심부대퇴동맥성형술을시행한군에서일차개존율이유의하게높았다 (P=0.009, Fig. 2B). Runoff score, 표재대퇴

4 28 대한혈관외과학회지 : 제 24 권제 1 호 2008 동맥과심부대퇴동맥의폐색정도등을변수로하여다변량분석을시행하였을때심부대퇴동맥의폐색정도만이일차개존율의독립적위험인자로분석되었다 (P=0.001, Odds ratio=2.090). 고찰다부위동맥폐색성질환이있는환자에서유입동맥수술의성공여부는대퇴동맥과무릎아래동맥의동맥경화성병변유무에따라심각한영향을받을수있는것으로알려져있다 (10,11). 또한서혜인대하방동맥의폐색성질환이동반될경우유입동맥수술만으로하지허혈증상을경감시키기어려운경우가많이있다 (12). 또한다부위동맥폐색성질환이있는경우유입동맥과유출동맥의수술을동시에시행할때환자의증상도경감시키고유입동맥수술의결과를더좋게할수있다는보고가있다 (12-14). 반면유입동맥과유출동맥에대한재건술을동시에시행할경우재원기간도길어질수있고환자의이환율과사망률을증가시킬수있다는보고들도있다 (2,15-17). 또한 Timaran 등 (18) 은장골동맥스텐트삽입시서혜인대하방동맥재건술을동시에시행하였을때스텐트의개존율에차이가없어유입동맥수술후임상증상의호전이없거나하지구제가필요한환자에서만유출동맥재건술을고려할것을권유하였다. 본연구에서는유출동맥의병변이심할수록, 즉 runoff score 가높을수록유입동맥수술의결과가나빴고유출동맥재건수중심부대퇴동맥성형술을시행한군에서만유입동맥수술의일차개존율이그렇지않은군보다높았으므로환자가수술의고위험군이아닐경우유입동맥재건술의결과를향상시키기위해심부대퇴동맥성형술을고려할수있을것으로생각된다. 역사적으로심부대퇴동맥성형술은단독으로는잘시행하지않는수술이지만이환율이낮고재원기간을줄일수있는효과적인수술법으로알려져있다 (19,20). 최근경피적혈관성형술과스텐트삽입술이수술을대체하면서접근의용이성때문에심부대퇴동맥보다는표재대퇴동맥으로직접접근하는경우가많아지면서심부대퇴동맥성형술에대해서는관심도가비교적낮다 (20). 심부대퇴동맥폐색성질환은특히당뇨가없는환자에서대부분병변의길이가짧고입구쪽병변이많아경피적방법으로성공적인치료가가능했던사례에대한보고들이늘어나고있다 (21-24). 본연구에서심부대퇴동맥성형술을시행한군에서유입동맥의개존율이현저히높았고, 대퇴동맥-슬와동맥우회술에서처럼추가적인무릎절개가필요없어다부위동맥폐색성질환이있는환자에서유입동맥수술후이수술을같이시행하는것이좋을것으로생각된다. 본연구의한계점은후향적인연구설계로인해일부환자들의전산화단층혈관촬영술영상이소실되어혈관조영술영상분석으로 runoff score를계산한경우가있었는데이와같이혈관조영술로 runoff score를계산한경우실제혈관의직경을정확히알수가없어측정값이부정확할수있었다. 그리고 runoff score는측정하려고하는수준직하방의폐색정도를계산에이용하는데총대퇴동맥수준의 runoff score를계산할경우표재대퇴동맥과심부대퇴동맥의폐색정도만분석의대상이된다. 따라서슬와동맥하방의 runoff score가미치는영향이분석의범위에들어가지않게되는데슬와동맥하방의 runoff score가총대퇴동맥상방혈관재건술의개존율에영향을미치지않는지를증명할수있는추가연구가필요할것으로생각된다. 또한본연구는폐색성혈관질환의수술적치료에국한된연구로향후경피적심부대퇴동맥성형술의역할에대한연구도시행되어야할것으로생각된다. 결 대동맥-장골동맥의폐색성질환이있는환자에서유출혈관의 runoff score가나쁠수록일차개존율이낮아져원위부의 runoff score는하지혈관수술의예후를예측할수있는수단이될수있을것으로생각된다. 또한유입동맥에대한수술을시행한경우심부대퇴동맥성형술을함께시행하여일차개존율을향상시킬수있을것으로생각된다. 론 REFERENCES 1) Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45 Suppl S:S ) Schneider PA. Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques. Semin Vasc Surg 2003;16: ) Ascer E, Veith FJ, Morin L, Lesser ML, Gupta SK, Samson RH, et al. Components of outflow resistance and their correlation with graft patency in lower extremity arterial reconstructions. J Vasc Surg 1984;1: ) Peterkin GA, LaMorte WW, Menzoian JO. Runoff resistance and early graft failure in infrainguinal bypass surgery. Arch Surg 1988;123: ) Belkin M, Raftery KB, Mackey WC, McLaughlin RL, Umphrey SE, Kunkemueller A, et al. A prospective study of the determinants of vein graft flow velocity: implications for graft surveillance. J Vasc Surg 1994;19:

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: 15 1 Vol. 15, No. 1, April, 1999 = Abstract = A Clinical Analysis of Chronic Aortoiliac Occlusive Disease Jin Myoung Huh, M.D., Woo Hyung Kwun, M.D.

: 15 1 Vol. 15, No. 1, April, 1999 = Abstract = A Clinical Analysis of Chronic Aortoiliac Occlusive Disease Jin Myoung Huh, M.D., Woo Hyung Kwun, M.D., Bo Yang Suh, M.D. and Koing Bo Kwun, M.D. Department