untitled

Size: px

Start display at page:

Download "untitled"

가흔 주
5 years ago
Views:

1 대한혈관외과학회지 : 제 25 권제 2 호 Vol. 25, No. 2, November 2009 버거병환자에서하지동맥우회술의임상적의의 삼성서울병원외과, 성형외과 2 김균지 ㆍ박의준 ㆍ윤우성 ㆍ문구현 2 ㆍ김동익 ㆍ김영욱 Arterial Bypasses for Patients with Buerger s Disease Gyun Ji Kim, M.D., Ui Jun Park, M.D., Woo Sung Yun, M.D., Goo Hyun Mun, M.D. 2, Dong Ik Kim, M.D. and Young Wook Kim, M.D. Departments of Surgery and Plastic Surgery 2, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Purpose: Buerger s disease (thromboangiitis obliterans) is a non-atherosclerotic inflammatory vasoocclusive disease that affects the small- and medium-sized vessels of the extremities, and especially in young smokers. It is known that abstinence of smoking is the most effective treatment for Buerger s disease and surgical treatment is not frequently done because its result is not as good as that for atherosclerosis. We performed this study to determine the clinical implications and the effectiveness of arterial bypass surgery for limb salvage in patients with Buerger s disease. Methods: We retrospectively reviewed the patients with Buerger s disease and who underwent arterial bypass surgery between September 2003 and August We followed the criteria of Shionoya that was reported in 998 to diagnose Buerger s disease. The indications of surgery were patients with disabling claudication, severe resting pain, non-healing ulcer or gangrene, and non-diseased proximal and distal arteries were available for anastomosis. We evaluated the patency of the grafts with duplex ultrasonography or CT angiography after surgery. Results: Arterial bypass surgery was performed in 6 lower extremities of 4 patients. An autologous venous graft was used in 2 limbs and a polytetrafluoroethylene graft was used in 4 limbs. Major amputation was performed in 2 limbs and reconstruction with a myocutaneous free flap after minor amputation was performed in 2 limbs. The patency rates of the arterial bypasses were 66.%, 66.% and 66.% at, 3 and 5 years, respectively, and the limb salvage rates were 92.9%, 84.4% and 84.4% at, 3 and 5 years, respectively. Conclusion: Arterial bypass surgery could be considered as a favorable limb salvage treatment for the Buerger s disease patients with limited indications. Key Words: Thromboangiitis obliterans, Bypass surgery, Patency rate, Limb salvage 중심단어 : 폐쇄혈전혈관염, 우회로조성술, 개존율, 사지구제 서 버거병 (Buerger s Disease) 은주로젊은연령층의흡연자에게서작거나중간크기이하의동맥및정맥에발생 접수일 : 2009 년 8 월 5 일, 승인일 : 2009 년 0 월 일책임저자 : 김영욱, 서울시강남구일원동 , 삼성서울병원혈관외과 Tel: , Fax: ywkim@skku.edu 론 하는폐쇄혈전혈관염으로서 908년 Leo Buerger가개념을세운이래그의이름을따라버거병으로널리알려졌다 (,2). 버거병은이전에는죽상동맥경화증과혼동되는경우가많았으나이와는구별되는분절성의염증성폐색소견을가지는별개의질환으로역학이나인종에따른분포등이시대에따라약간씩다르게보고되고있다 (3). 우리나라에서는전국 22개병원에서 986년 월부터 2003년 2월까지의의무기록을후향적으로조사하여한국인의동맥질환중버거병이차지하는비율을구한연구결과가 2005년에발표되었는데 998년 Shionoya(4) 27

28 대한혈관외과학회지 : 제 25 권제 2 호 2009 의버거병진단기준을적용하여 5가지진단기준을모두만족하는환자 군은 0.84% 로기존의통계보다는낮게보고되었다 (5). 그러나버거병의증상이주로하지의통증이나족부괴사, 파행등으로나타나고이로인한삶의질저하는물론직종변경이나조기퇴직등직업에미치는영향또한적지않음을고려할때적극적인치료가이루어져야할필요성이있다 (6).

2 28 대한혈관외과학회지 : 제 25 권제 2 호 2009 의버거병진단기준을적용하여 5가지진단기준을모두만족하는환자 군은 0.84% 로기존의통계보다는낮게보고되었다 (5). 그러나버거병의증상이주로하지의통증이나족부괴사, 파행등으로나타나고이로인한삶의질저하는물론직종변경이나조기퇴직등직업에미치는영향또한적지않음을고려할때적극적인치료가이루어져야할필요성이있다 (6). 지금까지금연이가장효과가뚜렷한치료방법으로알려져왔으며 (7) 항혈소판제제및프로스타글란딘제제의사용 (8), 요부교감신경절제술 (9), 동맥우회술등 (0) 이시도되어왔고최근에는줄기세포이식을통한치료적신생혈관형성에관한연구도활발히진행되고있다 (-3). 버거병에대한수술적치료인동맥우회술은동맥경화증의경우보다치료성과가좋지못하다고알려져있고 PubMed, 대한외과학회지, 대한혈관외과학회지를검색하였을때한국인의버거병에관한수술적치료를주제어로하는논문은극히드물었다. 따라서저자들은하지동맥우회술을시행받은버거병환자들을대상으로수술적응증, 수술방법, 수술성적등을알아보고자하였다. 방법 2003년 9월부터 2008년 8월까지삼성서울병원에서버거병으로진단받은환자의의무기록을후향적으로조사하였고자료가불충분한경우전화인터뷰를시행하였다. 진단은 998년 Shionoya가제안한기준 (4) 을따라 ) 흡연의기왕력이있고 2) 50세이전발병하였으며 3) 슬와동맥보다원위부동맥의폐색이있고 4) 상지의병변또는이동성표재정맥염을동반하거나 5) 흡연외에죽상동맥경화증의위험인자가없는환자로선정하였고이들중 4가지이상만족할경우대상에포함하였으며총 303명이검색되었다. 이들중하지동맥우회술은 4명의 6하지에서시행하였다. 이들중 2예는이전에본원에서수술후이식편폐색으로인한재수술이었으며, 2예는이전에타병원에서동맥수술을받은과거력이있었다. 재수술이라함은새로운우회로술을조성한경우로정의하였으며이전이식편의협착등으로인한부분적혈관성형술등은대상에서제외하였다. 또한문합부의위치에상관없이주된병변이슬와동맥보다원위부동맥폐색일경우는대상에포함하였다. 수술적응증은금연이나약물치료에도반응하지않고일상생활을저해하는심한하지파행증, 휴식성동통, 족부의허혈성궤양등을보이는환자들중동맥조영술소견에서근위부와원위부동맥에혈관병변이없는환자로제한하였다. 모든환자는남성이 었으며평균나이는 39.9±9. (25 55) 세였고평균발병연령은 32.9±9.7 (8 45) 세였다. 모든환자에서흡연의기왕력이있었다 (Table ). 수술후항혈소판제제, 프로스타글란딘 (lipoprostaglandin) 제제를복용케하였으며추적관찰기간동안동맥우회술의혈관개통여부는술후 주일, 개월, 6개월, 이후 년마다증상에무관하게혈관초음파검사혹은 CT-혈관조영술로진단하는것을원칙으로하였으나술후 개월이후에는환자마다검사시행시기에차이가있었다. 이식편개존율과하지구제율은 Kaplan-Meier 방법을이용하여계산하였다. 결 하지동맥우회술의근위문합부는표재대퇴동맥이 5예 (36%) 로가장많았고원위문합부는전경골동맥, 후경골 Table. Patient demographics and clinical data (n=6 limbs in 4 patients) Age (y) 39.9 ± 9. (range, 25 to 55) Age of symptom onset 32.9 ± 9.7 (range, 8 to 45) Gender, male 00% Ex- or current smoking 00% Indications for bypass surgery Disabling claudication 5 (3%) Rest pain 4 (25%) Non healing ulcer (6%) Toe or foot gangrene 6 (38%) Fig.. Superficial femoral artery - anterior tibial artery bypass with cephalic vein graft. 과

3 Gyun Ji Kim, et al:arterial Bypasses for Patients with Buerger s Disease 29 동맥이각각 4예 (29%) 씩있었다. 우회술의이식편은자가대복재정맥 0예 (62.6%), 상지정맥 2예 (2.5%) (Fig. ), polytetrafluoroethylene (PTFE) 인조혈관 4예 (25%) 가사용되었다 (Table 2). 하지동맥우회술을시행한 6예중 4 예에서는동측발가락절단술을시행하였고 예는중족골절단술, 2예는무릎아래하지절단술을시행하였다. 동측발가락절단술을시행한 4예중 3예는동맥우회술당시이미발가락조직이괴사되고재생가능성이없어보여동맥우회술과함께시행하였으며 예는술후 개월뒤이식편개존상태는양호하나이식편보다근위부혈관협착이발생하면서궤양이악화되어발가락절단술을시행하였다. 중족골절단술을시행한예는이식편폐색은없으나궤양이치유되지않는상태였으며무릎아래하지절단술을시행한 2예는이식편폐색이있었다. 동측발가락절단술 예및중족골절단술 예에서는넓은등근유리피판을이용하여결손부위를복원해주었다 (Fig. 2). 환자의증상개선여부는수술직후부터한달시점을기준으로하였으며 명에서호전, 3명에서안정, 2명에서악화소견을보였다 (Table 3). 동맥우회술을시행한후평균추적관찰기간은 33.5± 9.0 ( 67) 개월이었으며한명의환자는 개월이후추적관찰이불가능하였다. 수술후, 3, 5년이식편개 Table 2. Procedural details for infrainguinal* bypasses for Buerger s disease (n=4 limbs) Proximal anastomosis Common femoral artery 4 (29%) Superficial femoral artery 5 (36%) Above-knee popliteal artery 4 (29%) Below-knee popliteal artery (7%) Distal anastomosis Below-knee popliteal artery 3 (2%) Crural artery (79%) Anterior tibial artery 4 (29%) Posterior tibial artery 4 (29%) Peroneal artery 2 (4%) Dorsalis pedal artery (7%) Type of conduit Vein graft 2 (86%) Ipsilateral GSV 9 (64%) Contralateral GSV (7%) Arm vein 2 (4%) PTFE graft with distal vein cuff 2 (4%) GSV = great saphenous vein; PTFE = polytetrafluoroethylene. *One ilio-femoral bypass and one femoro-femoral bypasses using PTFE graft are not included in the Table. 존율은각각 66.%, 66.%, 66.% 이었으며수술후, 3, 5년하지구제율은각각 92.9%, 84.4%, 84.4% 였다 (Fig. 3). 고찰버거병의치료에관하여현재까지는금연이외에효과가뚜렷하게밝혀진방법이없다 (7). Olin 등 (3) 은금연은자발적인의지가가장중요한데버거병환자들이대부분젊은연령층이고낮은사회경제적지위에위치한경우가많아순응도가비교적좋지않고실제로교육수준이낮을수록효과적인금연이이루어지지않는다고하였다. 저자들의대상환자의경우추적관찰이소실된 명의환자를포함한 4명이외에는모두금연을실시하고있었는데이것은비교적높은저자들의이식편개존율에영향을미쳤을것으로생각된다. 그러나흡연이확인된세명중두명은족부궤양이있었으나동맥우회로술이후보존적치료를병행하며장기간에걸쳐궤양이호전된환자였으며한명은무릎아래하지절단술을시행받은환자임에도불구하고금연을하지않고있었다. 이로미루어보았을때수술후지속적인금연은물론하지의재생가능성이있을때악화를예방하고궁극적으로사지구제를위한금연의중요성을부각시키고경각심을일깨우는교육등이더욱적극적으로이루어져야할것으로생각된다. Willingendael 등 (4) 도말초동맥질환환자가동맥우회술을받은후에금연을하느냐흡연을지속하느냐에따른이식편개존율을조사한메타분석에서흡연을지속할경우그렇지않은경우에비해이식편의폐쇄율이세배임을보고하였고수술후환자의금연을돕기위한프로그램의마련이무엇보다중요함을강조하였다. 약물요법인프로스타글란딘제제의사용을금연과함께보조적으로활용한예는지금까지빈번하게보고되었다. European TAO study group(5) 에서는이중맹검법으로시행한경구용프로스타글란딘제제에관한연구결과대조군에비해실험군에서통증제거효과가있으며통계적으로유의한차이를보인다고발표하였고국내에서도 Ki와 Kim(6) 이이와유사한결과를보고하였다. 그러나버거병이보존적인방법으로치유되지않을때파행이나심한통증을유발하고족부의허혈성궤양을일으킬수있으며때로괴사로까지이어져결국하지절단을고려해야하는상황이발생할수있다. 버거병의주된환자군이젊은남성임을고려할때이질환이이들의삶의질에미치는영향과사회경제적손실을고려한다면더적극적인치료가이루어져야한다고사료된다. 이에수술적인치료를고려해볼수있는데수술방법으로는요부교감신경절제술과동맥우회술이있다. 요부교감신경절제술은피부및피하조직과같은표면적인

호 2009 Fig. 2. Extended limb salvage procedure: latissimus dorsi free flap after leg

(C, D) Foot wound coverage with dorsal pedal vessel based on myocutaneous free flap.

Changes of major symptoms of patients after leg bypass surgery Claudication Resting pain

4 30 대한혈관외과학회지 : 제 25 권 제 2 호 2009 Fig. 2. Extended limb salvage procedure: latissimus dorsi free flap after leg artery bypass surgery. (A, B) Latissimus dorsi myocutaneous free flap. (C, D) Foot wound coverage with dorsal pedal vessel based on myocutaneous free flap. Table 3. Changes of major symptoms of patients after leg bypass surgery Claudication Resting pain Non-healing ulcer Gangrene Total Improved Stable Worsened Total (n) 부위에 혈류를 증가시켜 허혈성 궤양의 치유에는 효과 가 있을 수 있으나 근육층과 같은 심부 조직의 혈류를 증가시키는 효과는 적어 파행증에는 효과가 없다고 보 고된 바 있다(9,7). Nakajima(8)는 프로스타글란딘 제제 가 널리 사용되면서 이 약제의 표피 혈류 개선 효과 때 Fig. 3. Primary patency rate and limb salvage rate. No. at risk at, 3, 5 years are 5, 8, 2, respectively.

5 Gyun Ji Kim, et al:arterial Bypasses for Patients with Buerger s Disease 3 문에버거병환자에서요부교감신경절제술이용도는더욱감소하였다고하였고 Sasajima 등 (0) 은버거병환자에서요부교감신경절제술을시행한경우동맥우회술의이식편폐쇄율이오히려높아지는결과를보고하였다 (0). 저자들의경우에도요부교감신경절제술은시행하지않았다. 심한파행증, 고식적치료에반응하지않는심한휴식성통증및허혈성궤양이있는환자에서보다적극적인치료방법으로동맥우회술을고려해볼수있다. 죽상동맥경화증환자에비해버거병환자에서수술의성적은좋지못한데그이유는버거병은슬관절이하작은동맥이폐색되므로기술적으로용이하지않고동반된표재성정맥염으로인해자가정맥이식편사용이불가능한경우가상대적으로빈번하며성공적인동맥우회술후에도혈관염의진행에따른이식편폐색의위험이따르기때문이다 (0). Dilege 등 (8) 은동맥우회술의성공률을높이기위하여병변이없는혈관을문합에이용하는것을강조하였고이를위해술전및술중혈관조영술을시행할것을권장하였다. 이들은술전동맥조영술에서문합에적합하다고판단되었던동맥의 25% 가술중부적합하였다고보고하였고부적합한혈관에문합부를설치할경우이식편조기폐쇄율이높았음을보고하였다. 하지동맥우회술의개존율을높이기위해서는이식편의선택도중요한데인조혈관보다는자가혈관이식편이더좋은성적을보인다는것이보편적인개념이다 (9). Bozkurt 등 (20) 은 9명의환자에게서 20하지의동맥우회술을시행하였는데자가대복재정맥 0예, PTFE 7예, 복합이식편 (composite graft) 3예씩을사용하였고각각의개존율을 70%, 50%, 33.3% 로보고하였다. 저자들도자가정맥을 2예 (75%), PTFE 인조혈관을 4예 (25%) 에서사용하였고마지막추적관찰시점까지각각 75%, 50% 에서개통이잘유지되고있었다. 저자들의연구에서 PTFE 인조혈관을사용한 4하지는동측및반대측대복재정맥의길이가불충분하거나혈관벽이너무얇고역류가있어사용이어려운경우, 혹은과거에이미사용한경우였다. Ohta 등 (6) 은 0명의버거병환자를대상으로한후향적연구에서총 46예의동맥우회술을검토하였다. 그들은우회술의이식편개존율은기대에미치지못하였지만이식편개통기간동안일단허혈성궤양이치유되고나면그후이식편폐색이생기더라도지체절단 (6%) 은예방할수있다고주장하였다. Bozkurt 등 (20) 도동맥우회술의개존이수개월뿐이라할지라도사지의궤양이치유되기에충분하며그후에이식편의폐쇄가이루어지더라도허혈성병변의재발을유발하지는않는다고보고하였다. 그들은총 20예의동맥우회술을시행하였고 2예 (0%) 에서사지절단을시행하였다. 그러나저자들의경우에는심한족부궤양및괴저로동맥우회술 및발가락절단술을동시에시행받은환자를제외하면한명은궤양이호전되었으나두명은이식편이개통되어있음에도불구하고궤양의호전이없어서각각 7개월, 개월뒤결국중족골절단술, 발가락절단술을시행하였다. 반면하지파행증이주된수술적응증이었던 예에서동반된족부궤양이호전되지않아재우회술을고려하였으나원위부혈관이좋지않아재수술은시행하지않았고프로스타글란딘복용등보존적치료로궤양이치유된경우가있었다. 저자들의대상환자에서하지절단은총 6예중 2예 (2.5%) 에서시행하였고 5년하지구제율은 84.4% 로서기존의보고들과비슷한비율을보였다. 따라서버거병에있어동맥우회술은족부궤양의완전치유의기대는충족시키지못하더라도환자의삶의질에심각한영향을미칠수있는주요하지절단을최소화할수있는방법으로고려해볼만하다고사료된다. 결 버거병은금연이가장효과적인치료법으로알려진질환으로현재까지수술적방법이치료에기여하는비중은비교적높지않았다. 그러나금연이나약물치료에효과를보이지않는환자, 심한파행증이있는환자, 특히심한휴식성동통및이와동반된허혈성족부궤양이있는환자에게선택적으로동맥우회술을시행할경우하지보존의효과를경험하였다. 버거병환자중하지동맥우회술을시행할수있는환자는흔치않지만적절한환자를선택할경우세심한혈관수술과더불어유리피판을이용한족부재건술은버거병환자의삶의질을향상시킬수있는적극적치료방법의하나로고려해볼가치가있는것으로생각된다. 론 REFERENCES ) Buerger L. Landmark publication from the American Journal of the Medical Sciences, Thrombo-angiitis obliterans: a study of the vascular lesions leading to presenile spontaneous gangrene' Am J Med Sci 2009;337: ) Luft FC. Leo Buerger ( ) revisited. Am J Med Sci 2009;337:287. 3) Olin JW, Young JR, Graor RA, Ruschhaupt WF, Bartholomew JR. The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease). Circulation 990;82 Suppl:IV3- IV8. 4) Shionoya S. Diagnostic criteria of Buerger's disease. Int J Cardiol 998;66 Suppl :S243-S245. 5) Park JS, Kim GE, Min SK, Park SC, Moon IS, Heo S, et al. Buerger's Disease in Korea. J Korean Soc Vasc Surg 2005;2:

6 32 대한혈관외과학회지 : 제 25 권제 2 호 ) Ohta T, Ishioashi H, Hosaka M, Sugimoto I. Clinical and social consequences of Buerger disease. J Vasc Surg 2004;39: ) Sayin A, Bozkurt AK, Tuzun H, Vural FS, Erdog G, Ozer M. Surgical treatment of Buerger's disease: experience with 26 patients. Cardiovasc Surg 993;: ) Nakajima N. The change in concept and surgical treatment on Buerger's disease: personal experience and review. Int J Cardiol 998;66 Suppl :S273-S280. 9) van der Stricht JP. Effect of lumbar sympathectomy on the lower extremity. J Cardiovasc Surg (Torino) 979;20: ) Sasajima T, Kubo Y, Inaba M, Goh K, Azuma N. Role of infrainguinal bypass in Buerger's disease: an eighteen-year experience. Eur J Vasc Endovasc Surg 997;3: ) Kim DI, Kim MJ, Joh JH, Shin SW, Do YS, Moon JY, et al. Angiogenesis facilitated by autologous whole bone marrow stem cell transplantation for Buerger's disease. Stem Cells 2006;24: ) Matoba S, Tatsumi T, Murohara T, Imaizumi T, Katsuda Y, Ito M, et al. Long-term clinical outcome after intramuscular implantation of bone marrow mononuclear cells (Therapeutic Angiogenesis by Cell Transplantation [TACT] trial) in patients with chronic limb ischemia. Am Heart J 2008;56: ) Burt RK, Testori A, Oyama Y, Rodriguez HE, Yaung K, Villa M, et al. Autologous peripheral blood CD33+ cell implantation for limb salvage in patients with critical limb ischemia. Bone Marrow Transplant. Forthcoming ) Willigendael EM, Teijink JA, Bartelink ML, Peters RJ, Buller HR, Prins MH. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg 2005;42: ) The European TAO Study Group. Oral iloprost in the treatment of thromboangiitis obliterans (Buerger's disease): a double-blind, randomised, placebo-controlled trial. Eur J Vasc Endovasc Surg 998;5: ) Ki SG, Kim YW. Therapeutic effects of lipo-prostaglandin E in Buerger's disease. J Korean Vasc Surg Soc 998;4: ) Shionoya S. Surgical treatment. In: Shionoya S, editor. Buerger's disease: pathology, diagnosis and treatment. Nagoya: The University of Nagoya Press; 990. p ) Dilege S, Aksoy M, Kayabali M, Genc FA, Senturk M, Baktiroglu S. Vascular reconstruction in Buerger's disease: is it feasible? Surg Today 2002;32: ) Klinkert P, Post PN, Breslau PJ, van Bockel JH. Saphenous vein versus PTFE for above-knee femoropopliteal bypass. A review of the literature. Eur J Vasc Endovasc Surg 2004;27: ) Bozkurt AK, Besirli K, Koksal C, Sirin G, Yuceyar L, Tuzun H, et al. Surgical treatment of Buerger's disease. Vascular 2004;2:92-97.

637

637 Peripheral Arterial Disease Yong Bok Koh, M.D. Department of General Surgery The Catholic University of Korea, College of Medicine, Kangnam St. Mary s Hospital E mail : ybkoh@catholic.ac.kr Abstract Peripheral