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1 Korean J Vasc Endovasc Surg 2012;28(1): 경동맥협착증에대한외번내막절제술의결과 영남대학교의과대학외과학교실 박정영ㆍ권우형ㆍ서보양 The Results of Eversion Endarterectomy for Carotid Artery Stenosis Jeong-Yeong Park, M.D., Woo-Hyung Kwun, M.D. and Bo-Yang Suh, M.D. Department of Suregry, Yeungnam University College of Medicine, Daegu, Korea Purpose: Potential benefits of eversion carotid endarterectomy (ecea) compared with conventional carotid enderterectomy (ccea) are more simple and faster reanastomosis with a low risk of restenosis. However, in Korea, ecea is not popular having only one report of ecea. This study aimed to investigate the results of ecea. Methods: From July 2008 to September 2010, authors performed 36 eceas for patients with carotid artery stenosis in our hospital. Patients' demographics and clinical data were retrospectively reviewed. Regarding early (<30 days) results including the frequency of postoperative stroke, myocardial infarction, cerebral hyperperfusion syndrome, bleeding, cranial nerve palsy, new brain lesions (NBLs) on diffuse-weighted MRI (DW-MRI) and mortality were examined. Mid-term results such as stroke, death and restenosis after over thirty days were also examined. Results: Mean age was 66.6 years old and 88.9% of the patients were male. Twenty-four patients (66.7%) had a previous neurological event in the preceding 6 months. A carotid shunt was used in 3 cases (8.3%) and mean carotid clamping time was 25.4 minutes. One case (2.8%) of non-disabling ipsilateral stroke, 1 case (2.8%) of wound hematoma and 1 case (2.8%) of cranial nerve palsy developed after operation. DW-MRI was conducted in 27 patients (75.0%) and NBLs were detected in 4 patients (11.1%). One case (2.8%) of restenosis was discovered during the follow-up period (mean, 9.0 months), and there were no strokes or death. Conclusion: Early and mid-term postoperative stroke and complication rates of ecea were acceptable in our series. However, to assess efficacy of ecea, further large-volumed and long-term follow-up studies are needed. Key Words: Carotid stenosis, Endarterectomy, Eversion technique 중심단어 : 경동맥협착증, 내막절제술, 외번술 서 다국적광범위무작위연구에따르면뇌졸중발생원인의하나인경동맥협착증에대한적절한치료는뇌졸 접수일 : 2012 년 1 월 27 일, 수정일 : 2012 년 2 월 17 일, 승인일 : 2012 년 2 월 20 일책임저자 : 권우형, 대구시남구현충로 , 영남대학교의료원외과 Tel: , Fax: whkwun@med.yu.ac.kr 론 중의위험과사망률을유의하게감소시키며, 그중진행성경동맥협착증의경우경동맥내막절제술은약물치료단독보다그효과가우수하다고보고하고있다 (1-3). 경동맥내막절제술은 1954년 Eastcott 등 (4) 에의해처음보고된후 50년이상경동맥협착증의치료로사용되어왔다. 고식적경동맥내막절제술은내경동맥을종절개하여죽상판을제거한후일차봉합혹은첩포 (patch) 혈관성형술을시행하는방법이다. 이와달리, 외번경동맥내막절제술은내경동맥을기시부에서가로절단하여이를외번시켜죽상판을제거하는술기로 1959년 De 32

Jeong-Yeong Park, et al: Eversion Carotid Endarterectomy 33 Bakey 등 (5) 에의해처음보고된이후 1980년대가되어서야 Jones (6), Kasprzak와 Raithel (7), Kieny 등 (8) 에의해본격적으로시행되었다.

하지만외번경동맥내막절제술의경우술중션트시행이어려우며고식적술기보다경동맥주위박리범위가넓어야하며경동맥팽대부압력수용체의기능저하를초래해술후고혈압또는뇌신경마비가발생할가능성에대한우려의목소리도있다 (12). 경동맥협착증의표준치료선택에있어서아직정확한기준은확립되지않았지만최근경동맥외번내막절제술의치료결과에대한보고들이증가하고있다. 그러나국내의경우치료결과에대한보고는아직미비한실정이다.

경동맥협착증은 3차원컴퓨터단층혈관조영술 (3-dimension computer tomographic angiography), 복합초음파 (duplex ultrasonography), 자기공명혈관조영술 (magnetic resonance angiography), 대퇴동맥경유뇌혈관조영술 (transfemoral cerebral angiogarphy)

일과성허혈발작또는뇌졸중등의신경학적증상을동반한경우경동맥협착이 North American Symptomatic Carotid Endarterectomy Trial (NASCET) 기준으로 70% 이상인경우에, 신경학적증상을동반하지않은경우경동맥협착이 80% 이상인경우에수술을시행하였으며, 병변이궤양을동반한경우에는경동맥협착이 50% 이상이면수술을시행하였다

2 Jeong-Yeong Park, et al: Eversion Carotid Endarterectomy 33 Bakey 등 (5) 에의해처음보고된이후 1980년대가되어서야 Jones (6), Kasprzak와 Raithel (7), Kieny 등 (8) 에의해본격적으로시행되었다. 외번경동맥내막절제술의경우고식적경동맥내막절제술에비해상대적으로술기가쉬워수술시간이짧으면서재봉합시첩포사용이필요없으며경동맥중가장직경이넓은경동맥팽대부에절개및봉합을시행하므로술후재협착의빈도가낮다고알려져있다 (9-11). 하지만외번경동맥내막절제술의경우술중션트시행이어려우며고식적술기보다경동맥주위박리범위가넓어야하며경동맥팽대부압력수용체의기능저하를초래해술후고혈압또는뇌신경마비가발생할가능성에대한우려의목소리도있다 (12). 경동맥협착증의표준치료선택에있어서아직정확한기준은확립되지않았지만최근경동맥외번내막절제술의치료결과에대한보고들이증가하고있다. 그러나국내의경우치료결과에대한보고는아직미비한실정이다. 이에저자들이최근경험한외번경동맥내막절제술의치료결과및합병증등을확인하고자하였다. 방법 2008년 7월부터 2010년 9월까지경동맥협착증으로영남대학교의료원혈관외과에서경동맥내막절제술을시행받은환자는총 50명이었으며이중외번경동맥내막절제술을시행받은 36명의환자를대상으로후향적연구를시행하였다. 경동맥협착증은 3차원컴퓨터단층혈관조영술 (3-dimension computer tomographic angiography), 복합초음파 (duplex ultrasonography), 자기공명혈관조영술 (magnetic resonance angiography), 대퇴동맥경유뇌혈관조영술 (transfemoral cerebral angiogarphy) 등을시행하여진단과함께경동맥협착의정도를평가하였다. 일과성허혈발작또는뇌졸중등의신경학적증상을동반한경우경동맥협착이 North American Symptomatic Carotid Endarterectomy Trial (NASCET) 기준으로 70% 이상인경우에, 신경학적증상을동반하지않은경우경동맥협착이 80% 이상인경우에수술을시행하였으며, 병변이궤양을동반한경우에는경동맥협착이 50% 이상이면수술을시행하였다 (13-15). 경동맥병변에대한수술은외번절제술시행초기이후부터총경동맥에광범위한협착을동반한경우를제외하고는가능한한모두외번경동맥내막절제술을시행하고자하였다. 모든수술은전신마취하에, Kasprzak와 Raithel (7) 의외번경동맥내막절제술에기초하여한명의혈관외과의사가시행하였다. 수술중에는경두개초음파검사 (transcranial Doppler), 뇌파검사 (electro encephalogram) 또는체성감각유발전위검사 (somatosensory evoked potentials) 등으로감시하였는데, 경두개초음파검사상뇌혈류가 50% 이상감소한경우, 뇌파검사상 α와 β 뇌파가느려지고진폭이 50% 이상감소한경우, 또는체성감각유발전위검사상이상변화를보이는경우 Inahara shunt를이용하여경동맥션팅를시행하였다 (Figs. 1, 2). 수술전후신경학적합병증유무를확인하기위해신경과전문의가지속적으로상태평가를실시하였다. 퇴원후외래경과관찰중에는신경과전문의와혈관외과전문의가임상학적검진을시행하였고, 첫 1년동안은 1 개월, 3개월, 6개월, 12개월에복합초음파를시행하였으며이후에는매년 1회검사를시행하였다. 수술후단기결과는심근경색, 사망, 동측의신경학적증상발생, 확산강조자기공명영상 (diffusion-weighted magnetic resonance imaging) 에서새로운뇌병변 (new brain Fig. 1. Pictures show the eversion carotid endarterectomy. (A) Complete oblique transection of internal carotid artery is performed at the bulb. (B) After normal outer arterial layer is everted, the plaque is extracted. (C) Extracted plaque. (D) End to end anastomosis is performed at the carotid bulb, the widest part of the artery.

2) Hypertension 22 (61.1) Diabetes mellitus 9 (25.0) Hypercholesterolemia 12 (33.3) Coronary artery disease 5 (13.9) Values are presented as number (%). TIA = transient ischemic attack.

3 34 Korean J Vasc Endovasc Surg Vol. 28, No. 1, 2012 Fig. 2. Selective shunt is inserted during eversion carotid endarterectomy. Table 1. Demographics of the enrolled patients (n=36) Gender Male 32 (88.9) Female 4 (11.1) Symptomatic 24 (66.7) TIA/amaurosis fugax 11 (30.6) Stroke 13 (36.1) Comorbidities of patients Smoking 17 (47.2) Hypertension 22 (61.1) Diabetes mellitus 9 (25.0) Hypercholesterolemia 12 (33.3) Coronary artery disease 5 (13.9) Values are presented as number (%). TIA = transient ischemic attack. lesion) 의발생, 뇌출혈, 뇌신경마비, 고뇌관류증후군등이술후 30일이내에일어난경우로정의하였으며중기결과는뇌경색혹은사망, 경동맥재협착등이 30일이후에일어난경우로정의하였다. 경동맥의재협착은동맥의지름이 50% 이상감소한경우그리고복합초음파상경동맥의최고수축기유속 (peak systolic velocity) 이 125 cm/s 이상인경우로정의하였다. 결 환자의평균나이는 66.6세 (51-80세) 였고남자가 32명 (88.9%), 여자가 4명 (11.1%) 이었다. 술전신경학적증상이있는환자가 24명 (66.7%) 이었고이중일과성허혈발작또는일과성흑암시 (amaurosis fugax) 가 11명, 뇌졸중이 13명이었다 (Table 1). 동반질환으로고혈압이 22명 (61.1%), 당뇨가 9명 (25.0%), 고콜레스테롤혈증이 12명 (33.3%) 그리고관상동맥질환이 5명 (13.9%) 이었으며 17 명 (47.2%) 에서흡연의기왕력이있었다. 3차원컴퓨터단 과 Table 2. Early results of the eversion carotid endarterectomy ( 30 days) Outcomes (n=36) Ipsilateral stroke 1 (2.8) Non-disabling 1 Disabling 0 New brain lesion on DW-MRI 4 (11.1) Myocardiac infarction 0 Wound hematoma 1 (2.8) Cranial nerve palsy 1 (2.8)* Hyperperfusion syndrome 0 Mortality 0 Values are presented as number (%) or number. DW-MRI = diffusion-weighted magnetic resonance imaging. *Transient hypoglossal nerve palsy. 층혈관조영술결과, 경동맥협착의정도는 NASCET의방법으로계산하였을때평균 77.1% (50-90%) 였으며병변에궤양을동반한경우가 10명 (27.8%), 2번째경추의몸통부위이상으로고위부에위치한경우가 3명 (8.3%) 이었다. 전예에서전신마취하에수술을시행하였으며술중경동맥겸자시간은평균 25.4분 (16-40분) 이었고경동맥션트를사용한경우가 3명 (8.3%) 이었다. 수술후조기뇌졸중은 1명 (2.8%) 에게서발생하여경미한구음장애 (dysarthria) 를호소하였으나후유증없이 증상에서회복하였다. 수술후 27명 (75.0%) 에게확산강조자기공명영상을촬영하였으며그중 4명 (11.1%) 에서새로운뇌병변이확인되었으나증상은발생하지않았다. 상처혈종은 1명 (2.8%) 에게서발생하였으나재수술없이회복하였다. 뇌신경마비는 1명 (2.8%) 에서발생하였으나일과성설하신경마비로경과관찰중후유증없이회복하였다. 그외심근경색, 고뇌관류증후군및조기사망이발생한경우없이모두퇴원하였다 (Table 2). 평균추적관찰기간은 9.0개월 (1-24개월) 이었으며 10 명 (27.8%) 을제외한 26명의환자가현재까지외래에서

4 Jeong-Yeong Park, et al: Eversion Carotid Endarterectomy 35 Table 3. Mid-term results of the eversion carotid endarterectomy (>30 days) Outcomes No. (%) (n=36) Stroke 0 Death 0 Restenosis* 1 (2.8) *>50%. 추적관찰중이다. 추적관찰동안 1명 (2.8%) 의환자에게서술후 3개월째에시행한복합초음파상경동맥직경이 50% 이상좁아진재협착이관찰되었다 (Table 3). 신경학적증상은없었으나궤양이의심되는소견이보여경동맥스텐트삽입술을시행후외래에서경과관찰중이다. 추적관찰기간동안새롭게뇌졸중이발생하거나사망한예는없었다. 고 경동맥내막절제술은크게고식적내막절제술과외번내막절제술로나뉜다. 고식적내막절제술의조기결과로심근경색은 0.5%, 동측의신경학적증상발생은 1.7%, 뇌신경마비는 4.7%, 상처혈종은 4.2% 가보고되었다 (16). 확산강조자기공명영상에서새로운뇌병변의발생은 10% (17), 고뇌관류증후군등은 1.9% (18) 로보고되고있으며이상의결과들은외번내막절제술과비교하였을때유의한차이가없다고보고되고있다. 경동맥내막절제술의술후중기결과는대개술후뇌졸중발생률, 사망률및경동맥재협착률등으로비교된다. Peiper 등 (19) 은외번경동맥내막절제술은고식적경동맥내막절제술과술후일과성허혈발작 (1.0% vs. 1.3%), 뇌졸중발생 (2.1% vs. 2.9%) 및사망률은차이가없다고보고하였다. Cao 등 (20) 의 Eversion Carotid Endarterectomy versus Standard Trial (EVEREST) 을포함하여다섯개의 trial을검토한 Cochrane systematic review에서는외번경동맥내막절제술과고식적경동맥내막절제술의조기사망률은각각 1.7% 와 2.6%, 조기사망률은 1.4% 와 1.7% 로유사한결과를나타내었다 (16). 몇몇비무작위후향적연구에따르면외번경동맥내막절제술은고식적술기에비해재협착률에서우수한성적을보인다고보고되었다. Kieny 등 (8) 에따르면외번경동맥내막절제술은 1.9%, 고식적경동맥내막절제술은 13.5% 의경동맥재협착률을보고하였다. Ballotta 등 (10) 의무작위전향적연구에서는술후 40개월뒤외번경동맥내막절제술이 0%, 첩포성형술을시행한고식적술 기가 4.7% 의경동맥재협착률을보였으며 6개월이내의경동맥폐쇄율은각각 1.2%, 7% 로외번경동맥내막절 찰 제술에서나은성적을보고하였다. Cochrane systematic review에서도재협착률은 2.5% vs. 5.2% 로외번경동맥내막절제술이고식적경동맥내막절제술에비해나은결과를보였다 (16). Wistrand 등 (21) 은고식적경동맥내막절제술에서외번내막절제술로술기전환시그과도기에서도안전하게술기를시행할수있다고연구보고하였다. 보고에따르면과도기의술후조기결과및동측뇌졸중발생률 (2.5% vs. 3.3%), 사망률 (1.3% vs. 3.3%) 은유의한차이가없었으며또한술기의어려움에대한주관적접근에있어서도두수술간차이가없었다. 하지만 Cao 등 (20) 의 EVEREST 보고에서는술후경동맥재협착률은외번경동맥내막절제술군에서는 2.8%, 첩포혈관성형술을동반한고식적경동맥내막절제술군에서는 1.5% 의빈도를보여유의한차이가없었다. Crawford 등 (22) 도외번경동맥내막절제술과첩포성형술을동반한고식적경동맥내막절제술간에경동맥재협착률은유사한것으로보고하였으며 Brothers (23) 는외번경동맥내막절제술을시행한첫 100명의환자에있어서외번경동맥내막절제술의재협착률 (38%) 이첩포혈관성형술을동반한고식적경동맥내막절제술 (6%) 보다유의하게더높다고보고한바있다. 본원에서는지난 2008년 6월부터 2010년 10월까지 36 예에서외번경동맥내막절제술을표준치료로시행하여왔으며현재평균 9개월간경과관찰중이다. 술후 30일이내뇌졸중의발생은 1예 (3%) 에서관찰되었으나후유증없이증상에서회복하였으며술후시행한확산강조자기공명영상에서새로운뇌병변이발생된경우는 4예 (15%) 에서발견되었으나이들모두에서증상은발생하지않았다. 뇌신경마비및상처혈종의발생은각각 3% 로 Cochrane systematic review의결과와비교했을때유의한차이가없었다 (4.2%, 4.7%) (16). 본연구기간동안경동맥재협착은 1명으로 2.8% 의재협착률을보여타연구와비교하였을때유의한차이는없었다. 경동맥재협착은경동맥스텐트삽입술로치료하였으며신경학적증상은보이지않은채현재까지외래에서경과관찰중이다. 본원에서의경동맥내막절제술은전예에서전신마취하에진행되는데비교적안정적인환자의상태를유지할수있으며, 술중환자의불안이나감정기복등이없이안전하게수술을진행할수있는장점이있다. 국내의경우경동맥협착증의표준치료로대부분고식적경동맥내막절제술을시행하고있으며외번경동맥내막절제술을시행하는센터는일부에국한되어있다. 이는수술을시행하는외과의사의술기선호도의영향및새로운술기로의전환시우려되는과도기때의수술결과, 고식적경동맥내막절제술과외번경동맥내막절제술의치료결과자체에대한논란으로국내연구결과가적은것이그한요인으로생각된다. 현재국내

5 36 Korean J Vasc Endovasc Surg Vol. 28, No. 1, 2012 에서는 Song 등 (24) 이 18예의외번경동맥내막절제술의조기결과를보고한것이외에는없는실정이다. 결 외번경동맥내막절제술은상대적으로쉬운술기와짧은겸자시간및짧은수술시간의장점을가지면서고식적경동맥내막절제술과비교해보았을때조기및중기결과또한유의한차이가없으므로국내에서도외번경동맥내막절제술은경동맥협착증치료의표준수술로손색없을것으로판단된다. 하지만장기적인결과의분석을위하여향후보다광범위하고지속적인연구가진행되어야할것이다. 론 REFERENCES 1) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991;325: ) Tokumaru GK. The role of carotid endarterectomy in the management of carotid artery disease and stroke. J Am Optom Assoc 1995;66: ) Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;273: ) Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954;267: ) De Bakey ME, Crawford ES, Cooley DA, Morris GC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian, and vertebral arteries. Ann Surg 1959; 149: ) Jones CE. Carotid eversion endarterectomy revisited. Am J Surg 1989;157: ) Kasprzak P, Raithel D. Eversion endarterectomy of the internal carotid artery. Vasa Suppl 1992;37: ) Kieny R, Hirsch D, Seiller C, Thiranos JC, Petit H. Does carotid eversion endarterectomy and reimplantation reduce the risk of restenosis? Ann Vasc Surg 1993;7: ) Cao P, Giordano G, De Rango P, Caporali S, Lenti M, Ricci S, et al. Eversion versus conventional carotid endarterectomy: a prospective study. Eur J Vasc Endovasc Surg 1997;14: ) Ballotta E, Renon L, Da Giau G, Toniato A, Baracchini C, Abbruzzese E, et al. A prospective randomized study on bilateral carotid endarterectomy: patching versus eversion. Ann Surg 2000;232: ) Radak D, Radevic B, Sternic N, Vucurevic G, Petrovic B, Ilijevski N, et al. Single center experience on eversion versus standard carotid endarterectomy: a prospective non-randomized study. Cardiovasc Surg 2000;8: ) Mehta M, Rahmani O, Dietzek AM, Mecenas J, Scher LA, Friedman SG, et al. Eversion technique increases the risk for post-carotid endarterectomy hypertension. J Vasc Surg 2001; 34: ) Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, et al. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009;37(4 Suppl): ) Moore WS, Barnett HJ, Beebe HG, Bernstein EF, Brener BJ, Brott T, et al. Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995;91: ) Dixon S, Pais SO, Raviola C, Gomes A, Machleder HI, Baker JD, et al. Natural history of nonstenotic, asymptomatic ulcerative lesions of the carotid artery: a further analysis. Arch Surg 1982;117: ) Cao PG, de Rango P, Zannetti S, Giordano G, Ricci S, Celani MG. Eversion versus conventional carotid endarterectomy for preventing stroke. Cochrane Database Syst Rev 2001;(1): CD ) Schnaudigel S, Groschel K, Pilgram SM, Kastrup A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke 2008; 39: ) Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg 2009;49: ) Peiper C, Nowack J, Ktenidis K, Reifenhauser W, Keresztury G, Horsch S. Eversion endarterectomy versus open thromboendarterectomy and patch plasty for the treatment of internal carotid artery stenosis. Eur J Vasc Endovasc Surg 1999;18: ) Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G, et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000;31: ) Wistrand J, Matzsch T, Goncalves I, Riva L, Dias NV. Changing from conventional to eversion endarterectomy in carotid artery disease: a safe transition process in the short and long term. Vasc Endovascular Surg 2010;44: ) Crawford RS, Chung TK, Hodgman T, Pedraza JD, Corey M, Cambria RP. Restenosis after eversion vs patch closure carotid endarterectomy. J Vasc Surg 2007;46: ) Brothers TE. Initial experience with eversion carotid endarterectomy: absence of a learning curve for the first 100 patients. J Vasc Surg 2005;42: ) Song IC, Kim HK, Hwang YH, Choi HH, Huh S. Early results of eversion carotid endarterectomy. Korean J Vasc Endovasc Surg 2010;26:30-35.

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untitled 경동맥검사 1. 적응증 경동맥초음파검사는다음과같은임상증상이나질환이의심될때시행되어야하며, 진료 현장에서검사가필요하다고판단된경우아래적응증에국한되지않고시행할수있다. 1) 임상증상 - 경동맥부위잡음 (carotid bruit) - 경동맥부위의박동성종괴 - 일과성흑암시 (amaurosis fugax) - 구음장애 (dysarthria) 2) 의심질환 - 쇄골하동맥도류증후군