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1 Case Report J Korean Geriatr Soc 2007:11(4): 영구심박동기삽입술후발생한급성혈전증에인한좌측팔머리정맥폐색 1 례 서울의료원내과, 영상진단학과 1 서인석ㆍ최준혁ㆍ남양훈ㆍ임지환ㆍ황호경 1 ㆍ원경헌 A Case of Left Brachiocephalic Vein Total Occlusion Due to Acute Thrombosis Soon after Permanent Pacemaker Insertion In-seok Seo, M.D., Jun-hyuk Choi, M.D., Yang-hoon Nam, M.D., Ji-whan Im, M.D., Ho-kyung Whang, M.D. 1, Kyung-heon Won, M.D. Departments of Internal Medicine and Radiology 1, Seoul Medical Center, Seoul, Korea Symptomatic pacing lead-associated thrombosis is very uncommon occurring in % of pacemaker implants. Especially thrombisis-induced total occlusion occures almost in late stage over several months to years but acute thrombosis occurring several days after venous pacing has not been reported. In this case, We performed upper limb venography in the patient who presented edema and pain of neck, left upper limb and headache as well as intermittent cough occurring in bending forward. A venogram confirmed acute thrombus completely occluding the left brachiocephalic vein and the patient received intravenous heparin and was maintained on warfarin. Repeated venography after treatment for 30 days revealed persistent thrombus with total occlusion which not be improved significantly copmpared to previous venogram and collateral veins diverting the blood to the contralateral side and into the superior vena cava was developed. The patient's symptoms resolved almost and that is likely to be due to the development of collateral venous channels. Key Words: Pacemaker, Thrombosis, Occlusion 서 론 정맥을통한영구심박동기삽입술은비교적안전하고합병증이적은시술로서부정맥환자의치료에많이시행되고있다 1). 비교적흔히볼수있는합병증으로는전극도자의이탈및파손, pacing and sensing 역치의증가, 심장천공, 감염등이있고경정맥인공심박조율기삽입술후겨드랑이 (axillary), 쇄골하 (subclavian), 팔머리 (brachiocephalic) 정맥및상대정맥 (superior vena cava) 등에서발생한혈전증에의한임상적증상을동반한완전폐색은매우드문합 교신저자 : 원경헌 , 서울특별시강남구삼성 1 동 서울의료원순환기내과 Tel: Fax: ykjes@nate.com 병증으로알려져있다. 특히이러한완전폐색은대부분수개월혹은수년에걸친후기혈전증에의해일어난증례들이대부분이었고, 시술수일내에발생한급성혈전증에의한폐색은보고된예가거의없었다. 따라서본저자는동결절기능부전 (sick sinus syndrome) 환자에서영구심박조율기삽입술후 2일만에좌측쇄골하정맥일부와팔머리정맥에급성혈전증및허탈로인한완전폐색이발생하여수일내좌측경부및상지의중력의존성부종과함께통증을호소한환자를경험하였고, 이러한증례가국내에게재된바없기에문헌고찰과함께보고하는바이다. 증례 환자 : 여자 63세주소 : 간헐적인어지러움증 December

2 In-seok Seo, et al. 현병력 : 약 5년전고혈압과발작성심방세동을진단받고, amiodarone 등약물치료를해오던중에내원 20일전부터하루에 2-3차례간헐적인심한어지러움증이발생하였고, 내원당일어지러움증의빈도및강도가악화되어응급실로내원하였다. 과거력 : 고혈압, 발작성심방세동으로약물치료를받고있었으며, 1년전급성담낭염및총담관결석으로복강경담낭절제술과유두괄약근절개술을받았다. 가족력 : 특이사항없음. 이학적소견 : 입원당시혈압은 116/66 mmhg, 맥박수는 42회 / 분, 호흡수 22회 / 분, 체온 36.5 였다. 급성병색을보이고있었으며, 청진소견상양측전폐야에서호흡음은비교적깨끗하였고, 이상심음은들리지않았으며, 맥박은규칙적이나느리게촉진되었다. 검사실소견 : 입원당시시행한혈액학적검사상백혈구 8,400 mm 3, 혈색소 12.7 g/dl, 헤마토크릿 39%, 혈소판 197,000 mm 3 이었다. 일반생화학검사는 AST/ALT 47/67 U/L, 총단백질 7.3 g/dl, 알부민 4.4 g/dl, 총빌리루빈 0.5 mg/dl, BUN/Cr 17/0.8 mg/dl, Na/k/Cl 136/4.7/105 mmol/l, 총콜레스테롤 222 mg/dl, 혈당 89 mg/dl 이었다. 방사선검사 : 흉부방사선사진은정상소견이었다. 심전도소견 : 분당 42회의동성서맥과 1도방실전도차단을보였다 (Fig. 1) 심초음파검사 : 경도의승모판폐쇄부전과삼첨판폐쇄부전, 경도의폐동맥고혈압및좌심실이완장애소견을 보였다. 24hr Holter 검사 : 본검사는모든약물을끊은 10일후시행하였다. 검사상가장긴동정지는 3.69 초였고, 그외수차례의동정지가관찰되었고, 이때마다어지러움증을보여증상을동반한동결절기능부전으로진단하였다 (Fig. 2). 치료및경과 : 동결절기능부전진단하에좌측쇄골하정맥으로접근하여 DDD형의영구심박동기를삽입하였다. 영구심박동기삽입후 1일째에발작성심방세동이발생하여심실조율이분당 150회이상증가하고심계항진을호소하여 VVI형으로모드를변경후심실조율은분당 65회로정상화되었다. 영구심박조율기삽입후 2일째되는날상지부종이나혈관확장은보이지않았으나, 걸을때좌측두부두통및어깨통증호소하였고, 그다음날에는지속적인증상호소함께중력에따른좌측상지및좌측경부쪽에부종및상체를숙일때나타나는간헐적기침이동반되었다. 이에대한원인을규명하기위해우선적으로컴퓨터단층촬영을시행하여 (Fig. 3A) 좌측팔머리정맥허탈소견을관찰하였고, 좌상지정맥조영술검사를시행하여 (Fig. 4B) 좌측쇄골하정맥의일부와좌측팔머리정맥에혈전으로인한완전폐색및우회정맥을통한우심방으로회귀혈류소견을보였다. 이에저자는영구심박동기삽입후급성혈전증및허탈에의한좌측팔머리정맥완전폐색으로진단하였다. 치료는 heparin 정주및장기적인 warfarin 투약으로 INR 유지하도록하였으며, 30일이지난후좌상지정맥조영술 (Fig. 4B) 및컴퓨 Fig. 1. This EKG shows sinus bradycardia with 1st degree AV block. A heart rate is 42 beat per minute and PR interval is 240 ms. 230 Vol. 11, No. 4

Pacemaker, Thrombosis, Occlusion Fig. 2. 24 hrs holter monitering shows episodes of sinus pause. A entire PQRST complex is missing and a pause ends with junctional beat. Fig. 4.

A significant collateral flow is also recognized. (B) shows a little improvement of thrombosis compared to previous venogram (A) but venous occlusion and collapse is not resolved. Fig. 3.

(B) Repeated CT shows no improvement compared to preveous CT,(A). 터단층촬영 (Fig. 3A) 을재차시행한결과좌측쇄골하정맥의일부및좌측팔머리정맥의완전폐색의정도는초기와별차이없었다. 그러나좌상지및좌측경부의부종과통증이많이완화되었으나, 상체를숙일때나타나는간헐적기침은지속되었다.

3 Pacemaker, Thrombosis, Occlusion Fig hrs holter monitering shows episodes of sinus pause. A entire PQRST complex is missing and a pause ends with junctional beat. Fig. 4. (A) A venogram via a left antecubital vein is showing complete occlusion of the left brachicephalic vein and central portion of left subclavian vein with filling defect due to thrombus. A significant collateral flow is also recognized. (B) shows a little improvement of thrombosis compared to previous venogram (A) but venous occlusion and collapse is not resolved. Fig. 3. (A) Enhaced CT shows permanent pacemaker via medial portion of left subclavian vein. Left subclavian and left brachiocephalic vein are collapsed. (B) Repeated CT shows no improvement compared to preveous CT,(A). 터단층촬영 (Fig. 3A) 을재차시행한결과좌측쇄골하정맥의일부및좌측팔머리정맥의완전폐색의정도는초기와별차이없었다. 그러나좌상지및좌측경부의부종과통증이많이완화되었으나, 상체를숙일때나타나는간헐적기침은지속되었다. 고 찰 하지심부정맥 (deep vein) 혈전증은비교적흔하게발생하지만, 상지심부정맥에서는혈전증발생이드물다. 상지심부정맥혈전증은자발적으로발생하는경우와기계적손상으로발생하는경우로나눌수있는데, 자발적인원인으로는적혈구증가증, 울혈성심부전등이있고기계적손상으로는쇄골골절, 상지의과도한사용, 자극성물질의정맥주입, 정맥내도관삽관이나인공심박동기의삽입등이있다 2). 경정맥영구심박동기삽입술의합병증인심부정맥혈전증은 30% 정도로흔히발생할수있으나, 대부분임상적으로증상이나문제가없는경우가많고 3), 임상적으로문제를일으키는경우는약 0.5-3% 로보고되고있다 4). 영구심박동기삽입후심부정맥혈전증이발생하는부위로는겨드랑이정맥 (axillary), 쇄골하정맥 (subclavian), 팔머리정맥 (brachiocephalic), 상대정맥 (superior vena cana) 등이고드물게우심방혈전증도발생할수있는데, 증상이나임상적문제를일으키는경우가드문이유는대부분의환자에서정맥혈전증이천천히일어나고, 우회정맥 (collateral vein) 이발달되어정맥혈이우심방으로들어갈수있기때문이다 4). 하지만드물게이환부위의부종, 통증및폐색전증과같이심각한문제가발생할수있고, 매우드물게우심방혈전증이발생할경우는삼첨판막폐쇄를일으켜급사의위험이있기때문에주의를기울여야한다 5,6). 임상적증상으로상대정맥증후군이발생할수도있는데점진적으로얼굴, 목, 상지의부종과청색증을보이고, 그외상체를앞으로숙일때기침, 두통, 연하곤란, 호흡곤란등이악화되는증상이동반되기도한다. 인공심박조율기삽입에따른합병증으로서상부정맥혈전증의병태생리는아직명확히밝혀지지않은상태이지만, 추정되는여러가지원인들이있다. 삽입술후 4-5 일이내초기에발생하는심부정맥혈전증의원인들로는외과적시술후유발되는과응고증과도관 (catheter) 이나전극도자가혈관내막을자극하여발생하는응고인자의분비등으로추정하고있다. 인공심박조율기삽입후 1 년이후에발생하는후기혈전증의원인으로는경정맥전 December

4 In-seok Seo, et al. 극도자에의한염증반응과그로인한조직의섬유화반응이있으며, 또한전극도자에의한정맥혈류의정체가악화요인이될수있다 7). 그외에도단일전극도자삽입에비하여여러개의전극도자를삽입 (Multiple leads) 했을경우혈전증발생의위험이높아질수있다는주장도있고 8), silicon lead가 polyurethane lead 보다혈전증발생위험이높았던동물실험결과도있었으며 9), 감염 10) 과심부전 11) 이원인이었던증례보고도있다. 경정맥영구심박동기를갖고있는환자에서상지의부종, 발적, 표층정맥의확장, 통증등이있을경우혈전증에의한심부정맥폐색을의심하고, 정맥조영술을시행해야한다. 하지만봉와직염으로잘못진단하여정맥혈전증의진단및치료가늦어지는경우가흔히있을수있고, 또한정맥도플러에서우회혈관 (collateral vessel) 을정상정맥으로판단하는경우가흔히있기때문에정상도플러소견일지라도심부정맥혈전증을의심하여정맥조영술을시행하여야한다 12). 경정맥영구심박동기삽입술후발생한심부정맥혈전증의치료는경증인경우 Heparin 단독으로가능하나 13), 대부분장기간의 warfarin 투약이선호되고있다. Streptokinase와 recombinant tissue plasminogen activator (r-tpa) 은영구심박동기삽입후발생한우심방혈전증과상대정맥폐색의치료에효과적이다. Khalid B et al. 14) 은 heparin 500 unit/day와함께 r-tpa을 1 mg/hr로 4일간정주하여치료하였고, Mugge et al 15) 은 r-tpa 10mg bolus 후 40mg/day 정주와동시에 heparin 정주로 APTT를 60-90초로유지하였으며, Cooper et al. 16) 은 r-tpa 100 mg을 2시간동안정주후 heparin으로 APTT 초로유지하여치료하였다. 이론적으로는혈전이용해될때이차적으로폐색전증이발생할위험이있으나, 현재까지보고된바는없다 14). 경정맥풍선확장술 (Percutaneous Transluminal Balloon Venoplasty) 는 thrombosis 나일차적치료 (primary treatment) 뿐만 15) 아니라혈전용해후남아있는상대정맥의협착 (stenosis) 도성공적으로치료할수있다 17). 특히후자는혈전증의재발을예방하기위한치료인데, 치료후섬유화의발생률이높다는한계가있다. 그외감염이동반된심부정맥혈전증은전극도자를조기에제거하여치료하여야한다 14). 본증례에서는급성혈전증및허탈로인한완전폐색에대해 heparin 과 warfarin의치료를바로시행하였으나, 30일이지난후관찰한추적관찰에서는완전폐색이호전되는양상을보이지않았다. 그러나환자의증상은많이 호전되었으며, 이는측부혈관의발달로인한혈액순환이원활해졌기때문으로추정된다. 따라서증상을동반한급성혈전증에의한완전폐색에있어서증상의완화는폐색의호전이외에측부혈관의발달정도에따라결정되어짐을시사한다. 요약 경정맥영구심박동기삽입술후임상적문제와증상을동반한심부정맥혈전증의유병률은 % 로써매우드물다특히이러한혈전증에의한완전폐색은대부분수개월혹은수년에걸친후기혈전증에의해일어나는경우가대부분이고, 시술수일내에발생한급성혈전증에의한폐색은보고된경우가거의없었다. 본증례에서는영구심박동기시술을받은후수일내에좌측경부및상지부종과통증및두통과상체를숙일시나타나는간헐적기침의증상이나타나상지정맥조영술을시행하였으며, 급성혈전증및허탈로기인된상지심부정맥폐색증으로진단되어 heparin 정주및지속적인 warfarin 치료를하였다. 30일이지난후추적검사에서완전폐색은초기와비교하여큰호전은없었으나, 측부혈관이보다발달하였다. 또한, 초기에보였던증상들은많이호전되었고, 이는완전폐색의호전이외에측부혈관의발달정도가증상호전에많이기여를한다는것을시사한다. 중심단어 : 영구심박동기, 혈전증, 완전폐색 참고문헌 1. Ryu K, Manabu S. Total venous obstruction. Japanese Circulation Journal November 1988;52: Prescott SM, Tikoff G. Deep venous thrombosis of the upper extremity: A reppraisal. Circulation 1979;59: Rajs J. Postmortem findings and possible causes of unexpected death in patients treated with intravenous pacing. Pacing Clin Electrophysiol 1983;6: Stoney WS, Addlestone RB. The incidence of venous thrombosis follwing long-term transvenous pacing. Ann Thorac Surg 1976;22: Redish GA, Anderson AL. Echocardiographic diagnosis of right atrial thromboembolism. J Am Coll Cardiol 1983; 232 Vol. 11, No. 4

5 Pacemaker, Thrombosis, Occlusion 1: van Kuyk M, Mols P, Englert M. Right atrial thrombus leading to pulmonary embolism. Br Heart J 1984;51: Mazzetti H, Dussaut A, Tentori C, Dussaut E, Lazzari JO. Superior vena cava occlusion and/or syndrome related to pacemaker leads. Am Heart J 1993;125: Robboy SJ, Harthorne JW, Leinbach RC, Sanders CA, Austen WG. Autopsy findings with permanent pervenous pacemakers. Circulation 1969;39: Palatianos GM, Dewanjee MK, Panoutsopoulos G. Comparative thrombogenicity of pacemaker leads. Pacing Clin Electrophysiol 1994;17: Goudevenos JA, Reid PG, Adams PC, Holden MP, Williams DO. Pacemaker-induced superior vena cava syndrome: Report of four cases and review of the litera ture. Pacing Clin Electrophysiol 1989;12: Stoney WS, Addlestone RB, Alford WC, Burrus GR, Rrist RA, Thomas CS. The incidence of venous thrombosis following long-term transvenous pacin. Ann Thorac Surg 1976;22: Jerry OC, Daisy G. Arm Edema, Subclavian Thrombosis, and Pacemakers A case Report. Angiology April 1998;49 (4): Brown AK, Anderson V. Resolution of right atrial thrombus shown by cross-sectional echo. Br Heart J 1985; 53: Khalid B, Nicholas MR, Rowarth AJ. Transvenous Pacing Lead-Induced Thrombosis. Cardiology 2000;93(3): Mugge A, Gulba D, Jost S, Daniel WG. Dissolution of a right atrial thrombus attached to permanent tussue type plasminogen activator. Am Heart J 1990;119: Cooper CJ, Dweik R, Gabby S. Treatment of pacemaker associated right atrial thrombus with a two hour infusion of r-tpa. Am Heart J 1993;126(1): Sunder SK, Elcon EA, Sivalingham K, Kumar A. SVC thrombosis due to pacing electrodes: Successful treatment with combined thrombolysis and angioplasty. Am Heart J 1992;123: December

Jksvs019(8-15).hwp

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