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1 Korean J Vasc Endovasc Surg 2012;28(1): 일자형이식편을이용한복부대동맥류수술후총장골동맥의변화양상 경북대학교의학전문대학원외과학교실 1, 대구가톨릭대학교병원혈관외과 2, 포항성모병원외과 3 우인택 1 ㆍ윤우성 2 ㆍ조자윤 1 ㆍ이경근 3 ㆍ김형기 1 ㆍ김지혜 1 ㆍ허승 1 Change of Common Iliac Artery after Abdominal Aortic Aneurysm Repair Using a Tube Graft In-Teak Woo, M.D. 1, Woo-Sung Yun, M.D. 2, Jayun Cho, M.D. 1, Kyung Keun Lee, M.D. 3, Hyung-Kee Kim, M.D. 1, Jihye Kim, R.N., R.V.T. 1 and Seung Huh, M.D. 1 1 Department of Surgery, Kyungpook National University School of Medicine, 2 Division of Vascular/Endovascular Surgery, Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, 3 Department of Surgery, Pohang St. Mary s Hospital, Pohang, Korea Purpose: It remains controversial whether to use a tube graft or a bifurcated graft during open abdominal aortic aneurysm (AAA) repair, due to the potential for progression or development of a common iliac artery (CIA) aneurysm. This study evaluated the fate of CIA after tubular AAA repair. Methods: On a retrospective basis, we reviewed 61 patients who underwent open AAA repair with a tube graft, between March 2000 and December Fifty-seven patients were included in this study; we excluded 4 cases in which the patients died in-hospital. Of those enrolled, 24 patients underwent follow-up computed tomography at least 1-year after surgery. CIAs were categorized into 3 groups: normal ( 12 mm), ectasia (range, 13 to 18 mm), and aneurysm (range, 19 to 25 mm). The incidence of CIA aneurysm rupture was investigated, and the expansion rate of CIA was calculated. Results: Mean patient age was 64 years and 73% of patients were male. Preoperatively, 8 patients had 2 normal CIAs, 14 patients had one CIA aneurysm at least, 27 patients had one CIA ectasia, and 8 patients were unknown. There was a mean follow-up of 51 months; no deaths were caused by rupture of CIA aneurysm, and no patient underwent invasive treatment for a CIA aneurysm. The mean follow-up for 24 patients with 48 CIAs was 45 months. The mean expansion rate of CIA was 0.5 mm/y. Conclusion: AAA repair using a tube graft was a safe and durable procedure. However, a bifurcated graft should be considered when patients are young and there is the expectation of a long life expectancy is anticipated allowing for a CIA expansion rate of 0.5 mm/y. Key Words: Abdominal aortic aneurysm, Common iliac artery aneurysm, Tube graft 중심단어 : 복부대동맥류, 총장골동맥류, 일자형이식편 서 론 접수일 : 2011 년 10 월 4 일, 수정일 : 2011 년 11 월 14 일, 승인일 : 2011 년 11 월 30 일책임저자 : 허승, 대구시중구동덕로 , 경북대학교병원외과 Tel: , Fax: shuh@knu.ac.kr 인체내에서동맥류가가장흔히발생하는곳은복부대동맥이며, 서구에서초음파를이용한 50세이상의인구를대상으로시행한선별검사에서복부대동맥류의유병률은 3-10% 로보고되고있다 (1). 총장골동맥류의경우단독으로발생하는경우는전체의약 11% 정도로적으 19

2 20 Korean J Vasc Endovasc Surg Vol. 28, No. 1, 2012 며 (2), 대부분복부대동맥류와동반하여발생하는데복부동맥류가있을시총장골동맥류가동반되는빈도는 5-46% 로다양하게보고되고있다 (3,4). 이러한총장골동맥류의존재유무는복부대동맥류수술시어떠한형태의인조혈관이식편 ( 일자형또는분지형 ) 을사용할것인지에영향을미친다. 총장골동맥류가없는경우에는일자형이식편사용의적응증이되나, 어느한쪽이라도임상적으로유의한총장골동맥류가있으면분지형이식편을사용하여야한다. 하지만, 수술시총장골동맥류가없어일자형이식편을이용해복부대동맥류만교정한경우, 술후추적관찰기간동안총장골동맥류의발생으로인해추가적인수술의위험성이있으므로이를방지하기위해최초수술시분지형이식편을이용하는것이좋다는주장이제기된바있다 (5). 하지만, 대다수의다른연구에서는수술후총장골동맥류가발생하여수술적치료가필요하였던경우가드물어일자형이식편이안전하게사용될수있다고보고되었다 (6-10). 현재까지이에대해한국인을대상으로한연구는보고된바가없기에, 저자들은일자형이식편을이용한복부대동맥류수술후총장골동맥의자연경과를조사해보고, 총장골동맥류로인한합병증의발생및이로인한추가적인수술의빈도를알아보고자하였다. 방 2000년 3월부터 2009년 12월까지경북대학교병원혈관외과에서복부대동맥류로수술을받은 152명중, 일자형을이용한동맥류교정술은 61명 (40%) 에서시행되었다. 이들의의무기록을후향적으로조사하여수술당시의임상양상과수술후생존기간동안총장골동맥류발생 Table 1. Patient characteristics (n=57) Characteristics Total Age (mean, y) 64 (31-83) Gender (male) 43 (73) Smoking 35 (61) Comorbidities Hypertension 36 (63) Diabetes 14 (25) Coronary artery disease 13 (23) Chronic renal insufficiency 11 (19) Chronic obstructive pulmonary disease 12 (21) Hypercholesterolemia 15 (26) Marfan s syndrome 3 (5) Takayasu s arteritis 1 (2) Ruptured abdominal aortic aneurysm 15 (26) Values are presented as number (%). 법 으로수술을받았거나총장골동맥류파열로인한사망유무를조사하였고, 추적관찰기간동안복부전산화단층촬영술 (computed tomography, CT) 을시행한환자를대상으로수술전후의총장골동맥직경을측정하여, 이들의직경변화를조사하였다. 대동맥및총장골동맥의직경은 CT 횡단면중가장큰크기를보이는단면에서혈관의외벽에서외벽까지의거리를측정하였고, 횡단면이장골동맥의수직단면이아니어서타원형으로나타난경우실제직경에부합하는단축직경을측정하였다. 미국혈관외과학회및국제심혈관학회의보고기준 (11) 에따라총장골동맥의경우정상 ( 12 mm), 확장 (ectasia, mm) 그리고동맥류 (aneurysm, mm) 로분류하였다. 결 일자형이식편을이용한환자 61명중수술후원내사망한 4명을제외한 57명의평균나이는 64세 (31-83세) 였으며그중남성이 73% 였다. 16명의환자는파열복부대동맥류였고, Marfan 증후군환자가 3명, Takayasu 동맥염환자가 1명있었으며나머지는퇴행성대동맥류였다. 그외동반질환은 Table 1과같았다. 이들중술전총장골동맥이양측모두정상인경우가 8예, 최소일측이라도동맥류가있었던경우가 14예, 최소일측이라도확장인경우가 27예였으며, 8예의경우술전 CT의부재로알수없었다. 술후현재까지평균추적관찰기간은 51개월 (1-124개월) 이었으며, 그중 15명은추적관찰중사망하였고, 1년, 3년, 5년생존율은각각 93%, 83%, 74% 였다. 사망원인으로가장흔한원인은심근경색증과악성종양이었으며총장골동맥류파열로인한사망은없었다 (Table 2). 1년이상의추적관찰기간동안 CT를 1회이상시행한환자는 24명 (48 총장골동맥 ) 이었으며, 총장골동맥직경별 CT 추적관찰결과는 Table 3에요약되어있다. 총 Table 2. Cause of death during follow-up after abdominal aortic aneurysm repair with a tube graft (n=15) Cause of death No. Myocardiac infarction 4 Acute renal failure 2 Malignancy 4* Pneumonia 1 Rupture of thoracic aortic aneurysm 1 Intracranial hemorrhage 1 Unknown 2 *1 gastric cancer, 1 common bile duct cancer, 1 lung cancer, 1 bladder cancer; Marfan s syndrome. 과

3 In-Teak Woo, et al: Iliac Artery after Tubular AAA Repair 21 Table 3. Change in common iliac artery (CIA) diameter after abdominal aortic aneurysm repair with tube graft (n=48) No. Mean diameter of CIA (mm) Preoperative Postoperative Mean follow-up duration (mo) Diameter change rate (mm/y) Normal ( ) 12.5 ( ) 41 (12-73) 0.5 Ectasia ( ) 17.6 ( ) 54 (12-97) 0.6 Aneurysm ( ) 20.9 ( ) 30 (12-85) 0.1 Total ( ) 16.7 ( ) 45 (12-97) 개총장골동맥의술전평균직경은 15.0 mm ( mm) 였고, 술후평균직경은 16.7 mm ( mm) 였다. 추적관찰기간중정상총장골동맥 15예중 5예 (33%) 가확장으로진행하였으며, 동맥류로진행한경우는없었다. 또한총 24예의확장총장골동맥에서동맥류로진행한경우는 6예 (25%) 있었다. 하지만총장골동맥류에대해수술적또는혈관내치료가시행되었던경우는없었다. 복부대동맥및총장골동맥박리가있었던경우수술후총장골동맥박리가교정되면서직경이 20.5 mm에서 19.0 mm로감소한예가 1예있었다. 총장골동맥직경증가율은 0.5±0.79 mm/y였다. 술전총장골동맥의직경별로나누어보았을때, 평균직경증가율은정상, 확장, 동맥류였던경우각각 0.5 mm/y, 0.6 mm/y, 0.1 mm/y였다. 환자의나이에따라평균직경증가율을비교해보았을때, 70세이하의경우 0.4 mm/y, 71세이상의경우 0.8 mm/y로나이가많은경우통계학적으로유의하게직경증가율이높았다 (P=0.014, Mann-Whitney test). 고찰일자형이식편의장점으로는분지형에비해원위문합부가한군데밖에없으며그직경이크다는것이다. 따라서혈관문합으로인한합병증을줄일수있고, 수술시간을단축시킬수있으며, 특히, 파열복부대동맥류의경우실혈량및수술사망률을줄일수있다 (12,13). 또한, 총장골동맥주변으로박리를적게하기때문에술중장골정맥이나요관의손상을방지할수있고, 자율신경손상으로인한성기능장애를줄일수있다는장점이있다 (14-16). 하지만장골동맥류가존재하는경우, 또는장골동맥협착이나폐색이있어우회로술이필요한경우, 원위부대동맥의심한석회화로문합이어려운경우등에서는분지형이식편을이용해야한다. 이러한경우동반된장골동맥질환 ( 동맥류또는폐색 ) 을동시에치료할수있고, 향후총장골동맥류발생을예방할수있다. 일자형이식편을이용한수술의장점에도불구하고, Plate 등 (5) 은 1,112명의복부대동맥류수술을받은환자를추적관찰한결과, 술후평균 5.2년후 6명에서총장 골동맥류가발생하였고, 이들중 2예는파열된경우였음을근거로복부대동맥류수술시분지형이식편을이용할것을권고하였다. 이후, 총장골동맥의직경변화와일자형이식편의안정성에대한연구들이시행되었으나, 대부분의연구결과는상이하다. 특히근래의연구들은총장골동맥직경을미국혈관외과학회및국제심혈관학회의보고기준에따라분류하여그예후를비교하였다. Sala 등 (7) 은일자형이식편을이용한수술후 CT를시행한 74명을평균 68개월간추적관찰한결과 2명 (2.7%) 에서총장골동맥류로인해추가적수술을시행하였지만, 이들은술전에이미총장골동맥직경이모두 30 mm인환자였다고보고하였다. 또한이들은수술전후의 CT에서총장골동맥직경을비교해보았을때, 18 mm 이상 30 mm 미만의직경을가지는총장골동맥류의경우 5년까지는그크기증가가미미하나 7년내지 8년이지난후에급격한크기변화를보이는것을관찰하였으며, 따라서상기직경의환자군중기대수명이 8년이상인경우분지형이식편을이용할것을권고하였다. 이러한결과를바탕으로유럽 5개병원에서일자형이식편을이용한복부대동맥류수술후의 CT 추적관찰결과, 147명중 3명 (2%) 이평균 4.8년후에총장골동맥류로수술을받았으나, 장골동맥직경이 18 mm 미만이었던경우에는 25 mm 이상의동맥류로진행한경우는없었다고한다 (9). Ballotta 등 (10) 은일자형이식편을이용한복부대동맥류수술을받은 207명의환자를대상으로평균 7.1년간 CT 추적관찰결과 25 mm 이상의총장골동맥류가발생한경우는단 3예로이들중수술적치료가필요한예가없음을보고하면서, 일자형이식편이안전하게사용될수있음을주장하였다. Huang 등 (8) 은총장골동맥류로치료받은 438명의환자를대상으로그치료결과와총장골동맥류의직경증가율을조사하였다. 전체환자중복부대동맥류와연관된총장골동맥류는 377명 (86%) 이었으며, 그중 50명 (13%) 은과거복부대동맥류수술후발생한총장골동맥류였다. 2.0 cm에서 2.5 cm 미만의직경을가진경우직경증가율은 2.6 mm/y였으며, 고혈압이동반된환자의경우유의하게직경증가율이높았다. Santilli 등 (6) 은 189명의총장골동맥류환자를평균 31.4개

4 22 Korean J Vasc Endovasc Surg Vol. 28, No. 1, 2012 월간초음파를이용하여추적관찰한결과 3 cm 이상의총장골동맥류의직경증가율은 2.6 mm/y인반면, 3 cm 미만의총장골동맥류의직경증가율은 1.1 mm/y로매우낮았음을보고하였다. 본연구결과수술후평균 51개월동안총장골동맥류파열이발생한경우는없었으며, 총장골동맥류에대한수술이시행된경우는없었다. 그리고총장골동맥의평균직경증가율은 0.5 mm/y로서구의연구결과에비해낮았다. 특이한점은술전직경이컸었던동맥류군에서정상군과확장군에비해직경증가율이더낮았다는것이다. La place의법칙에의하면혈관직경이클수록혈관벽에미치는장력이커지므로, 직경이큰혈관이더큰직경증가율을보일것으로생각된다. 하지만본연구에서는직경이큰동맥류군에서오히려직경증가율이더낮은것으로나왔다. 이는우선동맥류군의표본수가 9예로적었으며, 추적기간이다른군에비해짧았고, 특히, 그중 4예는추적관찰기간이 1년이었고, 1명은대동맥및총장골동맥박리가있어수술후오히려총장골동맥직경이감소한경우가포함되어있었기때문으로생각되며, 이는더많은추적관찰을시행하여비교해보아야할것이다. 결론결론적으로본연구대상환자들에서일자형이식편을이용한복부대동맥류수술은안전하게시행될수있었으며, 장기적으로도추가적수술이필요한경우는없었다. 하지만 10년이상장기생존이예상될경우, 총장골동맥의연간직경증가율이 0.5 mm임을고려하여선택적으로분지형이식편을사용하는것이필요하다. 근래국내에서타질환으로인한복부 CT 또는초음파검사가빈번히시행되고, 복부대동맥류에대한선별검사가이루어지면서 60세미만의비교적젊은나이에도복부대동맥류를진단받는경우가늘어나고있으므로 (17), 이식편선택시이를고려하는것이중요할것으로생각된다. 또한낮은빈도지만일자형이식편사용후총장골동맥류의파열및치료의적응증이되는총장골동맥류가발생함이보고되고있으며, 총장골동맥류의경우복부대동맥류에비해발견이어렵고, 무증상인경우가많아수술후정기적추적관찰은필수적이라생각된다. 본연구의제한사항으로는추적관찰기간이비교적짧다는점과전환자에서 CT 추적관찰이이루어지지않았다는점이다. 향후다기관연구를통해더많은수의환자를대상으로장기간의추적관찰을시행한다면더나은결과를얻을수있을것으로기대된다. REFERENCES 1) Wilmink AB, Quick CR. Epidemiology and potential for prevention of abdominal aortic aneurysm. Br J Surg 1998; 85: ) Lawrence PF, Gazak C, Bhirangi L, Jones B, Bhirangi K, Oderich G, et al. The epidemiology of surgically repaired aneurysms in the United States. J Vasc Surg 1999;30: ) Batt M, Delcourt A, Michiels JF, Hassen-Khodja R, Declemy S, Bariseel H, et al. Treatment of abdominal aortic aneurysms: importance of the bifurcated prosthesis. J Mal Vasc 1996;21 Suppl A: ) Olsen PS, Schroeder T, Agerskov K, Roder O, Sorensen S, Perko M, et al. Surgery for abdominal aortic aneurysms: a survey of 656 patients. J Cardiovasc Surg (Torino) 1991;32: ) Plate G, Hollier LA, O'Brien P, Pairolero PC, Cherry KJ, Kazmier FJ. Recurrent aneurysms and late vascular complications following repair of abdominal aortic aneurysms. Arch Surg 1985;120: ) Santilli SM, Wernsing SE, Lee ES. Expansion rates and outcomes for iliac artery aneurysms. J Vasc Surg 2000;31: ) Sala F, Hassen-Khodja R, Branchereau P, Berthet JP, Batt M, Mary H, et al. Outcome of common iliac arteries after aortoaortic graft placement during elective repair of infrarenal abdominal aortic aneurysms. J Vasc Surg 2002;36: ) Huang Y, Gloviczki P, Duncan AA, Kalra M, Hoskin TL, Oderich GS, et al. Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair. J Vasc Surg 2008;47: ) Hassen-Khodja R, Feugier P, Favre JP, Nevelsteen A, Ferreira J; University Association for Research in Vascular Surgery. Outcome of common iliac arteries after straight aortic tubegraft placement during elective repair of infrarenal abdominal aortic aneurysms. J Vasc Surg 2006;44: ) Ballotta E, Da Giau G, Gruppo M, Mazzalai F, Toniato A. Natural history of common iliac arteries after aorto-aortic graft insertion during elective open abdominal aortic aneurysm repair: a prospective study. Surgery 2008;144: ) Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991;13: ) Purdy RT, Beyer FC 3rd, McCann WD, Smith ID, Mann RH. Reduced aortic cross-clamp time in high-risk patients with abdominal aortic aneurysm. J Vasc Surg 1986;3: ) Snellen JP, Terpstra OT, van Urk H. The use of a straight

5 In-Teak Woo, et al: Iliac Artery after Tubular AAA Repair 23 tube graft decreases blood loss and operation time in patients with an abdominal aortic aneurysm. Neth J Surg 1984;36: ) Evans WE, Hayes JP. Tube graft replacement of abdominal aortic aneurysm. Am J Surg 1988;156: ) Friedman SG, Hardaway MY, Jurkiewicz AJ, Krishnasastry KV, Doscher W, Deckoff SL, et al. Late results of preferential use of tube versus bifurcation grafts for abdominal aortic aneurysmectomy. Ann Vasc Surg 1990;4: ) Glickman MH, Julian CC, Kimmins S, Evans WE. Aortic aneurysm: to tube or not to tube. Surgery 1982;91: ) Park YJ, Kim N, Kim YW. Investigation of current trend of AAA treatment in Korea. J Korean Surg Soc 2011;80:

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding