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지아 창
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1 대한혈관외과학회지 : 제 26 권제 3 호 Vol. 26, No. 3, November 2010 소복재정맥역류와무관한오금부위정맥류 서을대학교의과대학외과학교실 1, 영상의학교실 2 신용찬 1 ㆍ민승기 1 ㆍ박은아 2 ㆍ이활 2 ㆍ정진욱 2 ㆍ하종원 1 ㆍ김상준 1 Atypical Varicose Veins in the Popliteal Fossa Unrelated to Small Saphenous Vein Reflux Yong Chan Shin, M.D. 1, Seung Kee Min, M.D. 1, Eun Ah Park, M.D. 2, Whal Lee, M.D. 2, Jin Wook Chung, M.D. 2, Jong Won Ha, M.D. 1 and Sang Joon Kim, M.D. 1 Departments of Surgery 1 and Radiology 2, Seoul National University College of Medicine, Seoul, Korea Purpose: To analyze the causes, clinical features, and computed tomography (CT) images of atypical varicose veins in the popliteal fossa unrelated to small saphenous vein (SSV) reflux by three-dimensional CT venography (3D-CTV). Methods: A total of 1,476 limbs in 794 consecutive patients with varicose veins who underwent surgery from 2005 to 2009 were enrolled. The medical records, duplex ultrasound, and 3D-CTV images were analyzed retrospectively. Results: Varicose veins in the popliteal fossa (PFV) were found in 438 of 1,476 limbs; the PFV in 428 limbs (97.5%) were caused by SSV insufficiency. Ten limbs (2.5%) had atypical PFV unrelated to the SSV. Incompetent perforator of the PPF was found in six of ten limbs (four women and two men; median age, 58-years). The CEAP clinical classes were C2 in four limbs and C4 in two limbs. The PPF drained to the popliteal vein in five limbs and to the gastrocnemial vein in one limb. A perforator ligation was performed in all patients, and additional sclerotherapy was performed in one patient. Thigh or calf perforator insufficiency was found in three limbs (two women and one man; median age, 62.7-years). The CEAP clinical classes were C2 in two limbs and C3 in one limb. Great saphenous vein insufficiency with Giacomini vein reflux was found in one limb (woman, 67-years). Conclusion: An exact preoperative understanding of the anatomy and flow dynamics is essential for the proper treatment of rare atypical PFV. A preoperative evaluation with 3D-CTV can provide accurate anatomical information for the surgery. Key Words: Atypical varicose vein of popliteal fossa, Computed tomography venography 중심단어 : 오금부위특이정맥류, 전산화단층촬영정맥조영술 서 최근하지정맥류에대한관심이높아지면서그에대한 접수일 : 2010년 9월 25일, 수정일 : 2010년 10월 15일, 승인일 : 2010년 10월 19일책임저자 : 민승기, 서울시종로구대학로 101 우 , 서울대학교병원외과 Tel: , Fax: skminmd@snuh.org 론 해부학적지식이빠르게축적되고있다. 하지정맥류는대복재정맥역류, 소복재정맥역류혹은관통정맥역류에의해발생한다. 이중소복재정맥의정맥류수술은복잡한해부학적구조와개개인의다양한구조적변이때문에합병증및재발위험이높은것으로알려져있다 (1-3). 다리오금 (popliteal fossa) 부위에생긴정맥류의경우대부분소복재정맥의역류에기인한것이많으나, 소복재정맥과무관한원인의정맥류가존재한다. 최근 Delis 183

2 184 대한혈관외과학회지 : 제 26 권제 3 호 2010 등 (4) 은복재정맥과무관한오금부위정맥류에대해보고한바있다. 이러한특이한원인의정맥류를적절히치료하기위해서는수술전정확한해부학적, 혈류역학적정보가필수적이라할수있다. 혈관초음파 (duplex ultrasound) 는하지정맥의해부학적, 혈역학적정보를제공할수있기때문에정맥류진단의표준검사로서시행되고있고소복재정맥의역류를진단하는데필수적이다 (5,6). 최근 computed tomography (CT) 기술과컴퓨터를이용한영상처리기술의발달로 3차원 CT 정맥조영술이하지정맥류의수술전평가를위해시행되고있으며, 재발성정맥류, 다리오금의정맥류및골반정맥류와같은임상적으로어려운상황에서도그진단및치료에유용하다 (7). 저자들은수년전부터정맥류수술을위한하지정맥평가목적으로 3차원 CT 정맥조영술을도입하였고혈관초음파와함께총체적인해부학적및혈역학적정보를얻을수있었다 (8). 만성정맥질환에대한영상학적검사방법의눈부신발전에도불구하고현재까지다리오금정맥의혈역학적중요성및임상적역할등은많은부분확인되고있지않은실정이다. 저자들은최근 computed tomography venography (CTV) 를이용하여수술전소복재정맥류구조에대한정확한검사가가능하다는점을보고한바있다 (9). 이러한연구결과저자들은오금부위정맥류중소복재정맥역류와관계없는다른원인의정맥류가상당히존재함을알게되었다. 완벽한수술적치료를위해서는이러한비전형적정맥류의정확한수술전이해가매우중요하겠다. 따라서저자들은오금부위에생긴정맥류로내원한환자중전형적인소복재정맥의역류가아닌다른원인의정맥류들의유병률, 정맥역류의원인, 임상양상, CT 영상적구조등을분석하고자한다. 방법 2005년 1월부터 2009년 12월까지서울대학교병원에서하지정맥류로수술받은환자중오금부위정맥류가있는환자를대상으로하였다. 단순히모세혈관확장증이나세정맥확장증만있는환자나 CT 정맥조영술을시행하지받지않은환자는연구대상에서제외하였다. 환자의의무기록, 혈관초음파검사, CTV검사, 수술기록지등을후향적으로분석하였다. 오금부위정맥류의유병률, 정맥류의원인, 영상학적구조등에대하여분석하였다. 1) 수술전영상학적검사병력청취및신체검진후, 혈관초음파와 3D-CTV가시행되었다. 혈관초음파와 3D-CTV는대부분같은날에시행되었다. 3D-CTV를먼저시행하여용적묘사영상 (volume rendering image) 에서직경 1 mm 이상의관통정 맥들을확인, 표시한후혈관초음파를이용하여복재정맥, 관통정맥부전여부를평가하였다. 복재정맥의경우 1초이상, 관통정맥의경우 0.5초이상의역류가있을경우역류가존재한다고판정하였다. 혈관초음파는환자를 tilting table에서게한뒤 o 정도의 semierect position으로검사하였다. 정맥의역류측정은 calf muscle squeezing and release technique을사용하였다. 2) 3 차원재구성 모든얇은축단면영상들은컴퓨터를바탕으로한 3차원재구성소프트웨어 (Rapidia, Infinitt, Seoul, Korea) 를구동하는작업실로전송되었다. 각각의용적정보는 3차원프로그램을이용하여경험있는영상의학과전문의에의해 3차원으로재구성되었다. 관통정맥조사를위해상호순환하는용적표현영상과축, 시상, 관상영상을비교분석하였다 (10). 3) 수술적치료 수술전시행한환자의혈관초음파와 3D-CTV를통해하지정맥의해부학적구조를확인후수술을시행하였고, 수술중 3D-CTV 영상과실제수술진행상황을비교하며수술을진행하였다. 결 전체 794명의환자, 1,476하지의정맥류에대해수술을시행하였고, 이중오금부위의정맥류가있는하지는 438예이었다. 오금부위정맥류가소복재정맥의역류에서기인한것은총 428예 (97.5%) 였다. 소복재정맥이외의혈관역류로인한것은 10예 (2.5%) 로본연구의주대상으로분석되었다 ( 이하오금부위특이정맥류, atypical varicose vein in the popliteal fossa). 오금부위특이정맥류의원인은오금관통정맥부전에의한것이 6예, 넙다리혹은장딴지관통정맥부전이 3예, 그리고 intersaphenous vein (Giacomini vein) 정맥부전이 1예였다. 1) 오금관통정맥부전 (The insufficient perforator of the popliteal fossa; PPF) 오금관통정맥부전은 6예 ( 여자 4명, 남자 2명 ; 평균연령 58세 ) 에서발견되었다. 오른쪽이 4예, 왼쪽이 2예였다. CEAP 임상분류상 4예는 C2, 2예는 C4였다 (Table 1). 오금관통정맥부전은소복재정맥보다외측에위치한것이 2예, 내측에위치한것이 1예였고, 3예에서복재오금이음부 (saphenopopliteal junction) 의상방에위치하였다 (Figs. 1 3). 오금관통정맥과연결된심부정맥은오금정맥이 5 예, 비복근정맥이 1예였다. 동일하지의동반된다른정맥의이상은종아리중간부위의소복재정맥역류 2예, 대 과

Sex/Age CEAP Laterality Located to SSV Drained to Associated reflux 1 F/50 C2 Lt Medial PV CFV, Thigh perforator 2 F/66 C2 Lt Lateral PV 3 M/60 C2 Rt Cranial GNV SFV 4 F/54 C4 Rt Lateral PV SFV, PV 5

3 Yong Chan Shin, et al:atypical Varicose Veins in the Popliteal Fossa Unrelated to Small Saphenous Vein Reflux 185 Table 1. Characteristics of the patients with insufficient perforator of the popliteal fossa No. Sex/Age CEAP Laterality Located to SSV Drained to Associated reflux 1 F/50 C2 Lt Medial PV CFV, Thigh perforator 2 F/66 C2 Lt Lateral PV 3 M/60 C2 Rt Cranial GNV SFV 4 F/54 C4 Rt Lateral PV SFV, PV 5 M/62 C4 Rt Cranial PV SSV mid 6 F/56 C2 Rt Cranial PV SSV mid PV = popliteal vein; GNV = gastrocnemial vein; SFV = femoral vein; SSV = small saphenous vein. Fig. 1. Three-dimensional computed tomography venography imaging of the insufficient perforators of the popliteal fossa. The perforator is located lateral to small saphenous vein and drained to the popliteal vein. Fig. 2. Three-dimensional computed tomography venography imaging of varicosity of popliteal fossa of the right limb. The insufficient perforator of the popliteal fossa drained to the popliteal vein. 퇴정맥역류 2예, 총대퇴정맥역류및넙다리관통정맥역류 1예등이었다. 혈관초음파검사상오금관통정맥의평균직경은 0.37 cm, 최고속도는 cm/s, 역류시간은 5, ms로측정되었다. 6예모두관통정맥결찰술을시행받았다. 4예는동반된반대쪽하지의정맥부전으로입원하여수술을시행받고 2예는외래통원수술을시행받았다. 추가치료는 1예에서혈관경화요법을시행받았다. 수술후 6개월간추적관찰하였고, 재발이나신경손상등의합병증은발생하지않았다. 2) 넙다리혹은장딴지관통정맥부전 (Thigh or Calf perforator insufficiency) 넙다리혹은장딴지관통정맥부전은 3예 ( 여자 2명, 남자 1명 ; 평균연령 63세 ) 에서발견되었다. 오른쪽이 2예, 왼쪽이 1예였다 (Fig 4). CEAP 임상분류상 3예는 C2, 1예는 C3였다. 동일하지의동반된다른정맥의이상은대복재정맥역류 1예, 오금정맥역류 1예등이있었고, 기 타다른질환으로 1예의베이커낭종이있었다. 혈관초음파검사상넙다리및장딴지관통정맥부전이있던 3예의관통정맥은평균직경 0.42 cm, 최고속도 cm/s, 역류시간 4,033 ms로측정되었다 (Table 2). 환자는모두외래통원수술로관통정맥결찰술및정맥류절제술을시행하였고, 3개월간추적결과특이소견은없었다. 3) Intersaphenous 정맥 (Giacomini vein) 부전 Intersaphenous 정맥부전은 1예 ( 여자, 67세 ) 에서발견되었다 (Fig. 5). 영상학적검사상환자는대복재정맥역류가있었고, intersaphenous vein reflux가동반되어오금부위정맥류가발생하였다. 수술은대복재정맥고위결찰술및발거술, 관통정맥결찰술, 정맥류절제술을시행하였고, 1개월간의외래통한경과관찰후특이소견은없었다.

Color flow duplex imaging of venous reflux in the right perforator of the popliteal fossa on transverse section (A), and three-dimensional computed tomography venography imaging of

Three-dimensional computed tomography venography imaging of varicosity of popliteal fossa caused by the right upper thigh lateral perforator insufficiency. Fig. 5.

Hemodynamics of thigh or calf perforator insufficiency by duplex ultrasound Location Diameter Peak velocity Duration (cm) (cm/s) (ms) Mid thigh posterior 0.17 18.

4 186 대한혈관외과학회지 : 제 26 권제 3 호 2010 Fig. 3. Color flow duplex imaging of venous reflux in the right perforator of the popliteal fossa on transverse section (A), and three-dimensional computed tomography venography imaging of varicosity of popliteal fossa (B). The insufficient perforator of the popliteal fossa is located cranial to small saphenous vein and drained to the popliteal vein. Fig. 4. Three-dimensional computed tomography venography imaging of varicosity of popliteal fossa caused by the right upper thigh lateral perforator insufficiency. Fig. 5. Three-dimensional computed tomography venography imaging of varicosity of popliteal fossa and refluxed Giacomini vein of the left limb. Table 2. Hemodynamics of thigh or calf perforator insufficiency by duplex ultrasound Location Diameter Peak velocity Duration (cm) (cm/s) (ms) Mid thigh posterior ,040 Upper calf posterior ,620 Upper calf lateral ,439 Median ,033 고 Dodd(11) 는소복재정맥과관련없이다리오금의피하조직에서발생하는무릎후방, 넙다리하부및장딴지상부의얕은정맥가지들에대하여처음으로보고하였 찰 다. 그가시행했던 444예의하지정맥류수술가운데 20% 에서이와같은정맥을확인하였다. 다리오금정맥으로알려진이정맥들은매우복잡한주행을가지고있으며주변의크고작은정맥가지들과조밀한그물망을형성하고있다 (12). 다리오금정맥은인접한대복재정맥및소복재정맥가지들과연결되어있어서로간의정맥역류에영향을받을수있다. Delis 등 (13) 은다리오금정맥류 1,076하지의수술결과정맥류의 3.8% 는다리오금내의심부정맥으로연결되었다고보고하였다. 이후 Delis 등 (4) 은 818예의하지정맥류수술가운데 24예 (2.93%) 에서다리오금정맥류를확인하였는데, 이들모두심부근막을관통하여 96% 에서오금정맥과, 4% 에서비복근정맥과연결되어있었다. 저자들의경우, 오금부위특이정맥류는오금부위정맥류 438예가운데 10예 (2.5%) 에서확인할수있었다. 오금관통정맥부전을보인 6하지

5 Yong Chan Shin, et al:atypical Varicose Veins in the Popliteal Fossa Unrelated to Small Saphenous Vein Reflux 187 가운데 5하지 (83.3%) 는오금정맥과, 1하지 (16.7%) 는비복근정맥과연결되어있었다. 오금부위특이정맥류는드물고, 소복재정맥과가까이위치하고있어서숙련된검사자가아니라면혈관초음파검사시소복재정맥으로오인하거나놓치기가쉽다. 이의정확한진단이선행되지않는다면수술후재발을피하기힘들것이다. 따라서혈관초음파검사자들은이러한특이한해부학적원인이있음을충분히이해하여야되겠다. 저자들은수년전부터하지정맥평가목적으로 3차원 CT 정맥조영술을도입하여혈관초음파와함께이전보다더좋은해부학적및혈류역학적정보를얻을수있었다. 그결과, 수술전영상학적검사들을통해오금부위특이정맥류의정확한원인을확인, 그원인에맞는수술을시행할수있었다. 수술후외래를통한경과관찰결과, 다른원인에의한정맥류수술과마찬가지로합병증및재발이적었으며, 정확한접근이가능하였기때문에미용적인측면에서도환자들의만족도는높았다. 결론적으로오금부위의정맥류는다양한원인에의해발생하며그치료를위해정확한진단및수술이필수적이다. 3차원 CT 정맥조영술의시행은혈관초음파와함께오금부위에서발생하는특이정맥류에대한정확한원인파악및해부학적구조의이해를가능하게하였고적절한수술과재발방지에중요한역할을할것으로기대한다. REFERENCES 1) Critchley G, Handa A, Maw A, Harvey A, Harvey MR, Corbett CR. Complications of varicose vein surgery. Ann R Coll Surg Engl 1997;79: ) Doran FS, Barkat S. The management of recurrent varicose veins. Ann R Coll Surg Engl 1981;63: ) Tong Y, Royle J. Recurrent varicose veins after short saphenous vein surgery: a duplex ultrasound study. Cardiovasc Surg 1996;4: ) Delis KT, Knaggs AL, Hobbs JT, Vandendriessche MA. The nonsaphenous vein of the popliteal fossa: prevalence, patterns of reflux, hemodynamic quantification, and clinical significance. J Vasc Surg 2006;44: ) Vasdekis SN, Clarke GH, Hobbs JT, Nicolaides AN. Evaluation of non-invasive and invasive methods in the assessment of short saphenous vein termination. Br J Surg 1989;76: ) Winterborn RJ, Campbell WB, Heather BP, Earnshaw JJ. The management of short saphenous varicose veins: a survey of the members of the vascular surgical society of Great Britain and Ireland. Eur J Vasc Endovasc Surg 2004;28: ) Uhl JF, Verdeille S, Martin-Bouyer Y. Three-dimensional spiral CT venography for the pre-operative assessment of varicose patients. Vasa 2003;32: ) Min SK, Kim SY, Park YJ, Lee W, Jung IM, Lee T, et al. Role of three-dimensional computed tomography venography as a powerful navigator for varicose vein surgery. J Vasc Surg 2010;51: ) Min SK, Min SI, Kim SY, Ahn SH, Jung IM, Lee T, et al. Evaluation of surgical anatomy of varicose vein by threedimensional computed tomography venography [abstract]. Ann Vasc Dis 2010;3(Suppl):S ) Lee W, Chung JW, Yin YH, Jae HJ, Kim SJ, Ha J, et al. Three-Dimensional CT venography of varicose veins of the lower extremity: image quality and comparison with doppler sonography. AJR Am J Roentgenol 2008;191: ) Dodd H. The Varicose Tributaries of the Popliteal Vein. Br J Surg 1965;52: ) Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Mansour MA, et al. Nonsaphenous superficial vein reflux. J Vasc Surg 2001;34: ) Delis K, Hobbs JT, Vandendreissche M, Ibegbuna V, Nicolaides AN. The vein of the popliteal fossa [abstract]. Br J Surg 1997;84(Suppl 2):158.

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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