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1 Korean J Fam Med. 2009;30: doi: /kjfm 양팔의혈압차이로발견한빗장밑동맥도루증후군 (Subclavian Steal Syndrome) 을스텐트삽입술로치료한환자증례 Case Report 김원백, 오미경 *, 이수희, 노진, 김하경, 김진영, 정상식 1, 정승문 2 울산대학교의과대학강릉아산병원가정의학교실, 1 순환기내과학교실, 2 방사선과학교실 A Case of Successful Correction of Subclavian Steal Syndrome by Percutaneus Transluminal Angioplasty with Stenting Who Found Incidentally Significant Interarm Blood Pressure Difference Won-Back Kim, Mi-Kyeong Oh*, Soo-Hee Lee, Jin Roh, Haa-Gyoung Kim, Jin-Young Kim, Sang-Sig Cheong 1, Seung- Mun Jung 2 Departments of Family Medicine, 1 Cardiology and 2 Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea A case of successful correction of subclavian steal syndrome by percutaneous transluminal angioplasty with stenting in a male patient who found incidentally significant interarm blood pressure difference. Small difference in blood pressure (BP) between two arms is a relatively common. Significant interarm BP difference is a potential marker of peripheral vascular disease such as subclavian artery stenosis and a predictor of cardiovascular disease. The subclavian steal syndrome is a condition that results from stenosis of subclavian artery proximal to the vertebral artery. The resulting symptoms are vertebrobasilar insufficiency symptoms due to reversal of blood flow from the contralateral vertebral and basilar artery into the ipsilateral upper extremity vessels and arm ischemic symptoms. Stenotic lesion of subclavian artery has traditionally been treated surgically. However recent trends are undergoing a paradigm shift from open surgery to endovascular approach. We report a patient with subclavian steal syndrome who found incidentally 35 mmhg interarm systolic BP difference. It was successfully treated by percutaneus transradial angioplasty with stenting on stenotic lesion of the subclavian artery. Keywords: Interarm Blood Pressure Difference; Subclavian Steal Syndrome; Peripheral Vascular Disease 서론 Received: August 12, 2009, Accepted: November 20, 2009 *Corresponding Author: Mi-Kyeong Oh Tel: , Fax: omk@gnah.co.kr Korean Journal of Family Medicine Copyright 2009 by The Korean Academy of Family Medicine 고혈압환자의대부분은일차의료에서치료를받고있으며, 일차의료에서혈압을정확히측정하는것은심혈관계질환으로인한사망률을낮추는첫걸음이다. 지금까지는고혈압을진단할때양쪽팔의혈압을측정하여, 만약차이가있으면재차측정하여높은쪽의혈압을기준으로하며, 이후혈압을잴때는높은쪽의팔에서혈압을측정하도록가이드라인을제시하고있다. 1) 양팔의혈압은정상인에있어서도약간씩 가정의학회지 Vol. 30, No. 12 Dec

Won-Back Kim, et al: A Case of Successful Steal Syndrome Who Found Incidentally Significant Interarm Blood Pressure Difference 은차이가있을수있으나그차가심할수록동맥경화증으로인한말초혈관질환을시사하고, 심혈관계질환의이환율과사망률이높아진다.

3,4) 빗장밑동맥도루증후군 (subclavian steal syndrome) 은폐쇄성동맥질환의일종으로빗장밑동맥의협착또는폐쇄로인하여나타난현상을의미하며, 증상은뇌기저부허혈증상과병변측의상지허혈증상으로나타나고, 치료는수술적방법과혈관중재시술을통하여혈류를재개하는방법이있다.

2 Won-Back Kim, et al: A Case of Successful Steal Syndrome Who Found Incidentally Significant Interarm Blood Pressure Difference 은차이가있을수있으나그차가심할수록동맥경화증으로인한말초혈관질환을시사하고, 심혈관계질환의이환율과사망률이높아진다. 2) 따라서양팔의혈압차는, 발목상완지수 (ankle-brachial index) 와같이동맥경화증의간접적지표가될수있을것이라고생각할수있다. 3,4) 빗장밑동맥도루증후군 (subclavian steal syndrome) 은폐쇄성동맥질환의일종으로빗장밑동맥의협착또는폐쇄로인하여나타난현상을의미하며, 증상은뇌기저부허혈증상과병변측의상지허혈증상으로나타나고, 치료는수술적방법과혈관중재시술을통하여혈류를재개하는방법이있다. 5) 저자들은힘든작업후에어지러움과말이꼬이는듯한느낌을주소로내원한 42세남자환자로부터진찰중양팔의수축기혈압의차가 35 mmhg정도관찰되어정밀검사한결과좌측빗장밑동맥도루증후군을발견하였다. 국내에서는보고된적이없는, 요골동맥 (radial artery) 을통한경피적혈관성형술및스텐트삽입술로비교적간단하게, 성공적으로치료한경험이있기에문헌고찰과함께보고하고자한다. 증례 중장비기술자인 42세남자가힘든작업후에나타나는어지러움과말이꼬이는증상으로내원하였다. 환자는내원 1주일전부터일을많이하면어지럽고, 머리가멍한느낌이들면서발음이정확하지않고말이꼬이는듯한느낌이든다고하 였고이외다른증상은호소하지않았다. 내원 6개월전고혈압진단을받고항고혈제를복용중이었으나그이외다른기저질환은없었고, 가족력상에서도어머니가고혈압이있는것이외에는특이소견이없었다. 그리고이전에다른원인으로약물이나수술적치료를받은병력도없었다. 하루 2갑씩 17년간흡연하였으나내원 1개월전부터금연중에있으며, 10 년이상매일소주 1병정도음주하는, 문제음주자였으나내원 9개월전부터술을마시지않고있었다. 내원당시수은혈압계로측정한우측상완혈압이 170/ 110 mmhg, 왼쪽상완혈압이 135/100 mmhg으로측정되었고, 좌측경부에서동맥잡음 (bruit) 이들렸으며, 좌측요골동맥박동이우측에비해약하게촉지되었다. 그러나양팔의온도차이는느껴지지않았고, 좌측상지의근육위축, 수지괴사, 이상감각등의소견은없었다. 그외에호흡수, 맥박수, 체온, 비만도등의생체지수는정상범위였으며, 이학적검사와신경학적검사에서도다른이상소견은없었다. 혈액검사에서는고감도 C-반응성단백질 (hs-crp) 0.10 mg/dl, 중성지방 (triglyceride) 286 mg/dl로상승되어있었으나저밀도지단백 (LDL) 콜레스테롤 96 mg/dl, 고밀도지단백 (HDL) 콜레스테롤 36 mg/dl로정상수치였고그이외다른혈액검사수치들도정상범위를보였다. 흉부 X선검사도특이소견은보이지않았다. 양팔의혈압차이를재확인하고자시행했던도플러소견은우측상완동맥압이 151 mmhg, 우측요골동맥압이 149 mmhg 였고, 좌측은각각 131 mmhg, 130 mmhg로양팔의혈 Figure 1. MR angiogram of brain and neck artery showing a significant stenosis in proximal left subclavian artery. Figure 2. Percutaneous transradial catheter angiogram showing a 75% stenosis in the proximal left subclavian artery. 980 Vol. 30, No. 12 Dec 2009 Korean J Fam Med

김원백외 : 양팔의혈압차이로발견한빗장밑동맥도루증후군 (Subclavian Steal Syndrome) 환자증례 Figure 3.

Retrograde filling of contrast from right vertebral artery into left vertebral artery 'disappeared' in the post-stent subclavian artery angiogram. Figure 4.

어지럼증과말더듬증 (dysathria) 의원인을알기위하여시행하였던뇌혈관자기공명영상에서는뇌실질에이상소견은발견되지않았으나자기공명혈관촬영에서좌측빗장밑동맥 (subclavian artery) 근위부가현저하게좁아져있는소견을관찰할수있었다 (Figure 1).

3 김원백외 : 양팔의혈압차이로발견한빗장밑동맥도루증후군 (Subclavian Steal Syndrome) 환자증례 Figure 3. The retrograde filling of contrast from right vertebral artery into left vertebral artery and post-stenotic subclavian artery showed before angioplasty. Figure 5. Retrograde filling of contrast from right vertebral artery into left vertebral artery 'disappeared' in the post-stent subclavian artery angiogram. Figure 4. Antegrade flow into left subclavian artery resumed after angioplasty with stenting and the left vertebral artery reappeared in the post-stent subclavian artery angiogram. 압의차가 20 mmhg 정도의차이를보였다. 어지럼증과말더듬증 (dysathria) 의원인을알기위하여시행하였던뇌혈관자기공명영상에서는뇌실질에이상소견은발견되지않았으나자기공명혈관촬영에서좌측빗장밑동맥 (subclavian artery) 근위부가현저하게좁아져있는소견을관찰할수있었다 (Figure 1). 빗장밑동맥도루신드롬의진단을위해순환기내과와협진하여혈관조영술을시행한결과양측목동맥 및뇌동맥에서좁아진소견은관찰되지않았고, 왼쪽빗장밑동맥근위부가약 75% 협착되어있는것을확인할수있었으며 (Figure 2), 또한우측척추동맥으로부터좌측척추동맥, 좌측상완동맥으로역류하는혈류의역행을관찰할수있었다 (Figure 3). 협착된부위를치료하기위해우측요골동맥을천자후유도철심을왼쪽빗장밑동맥까지삽입하여풍선카테터로혈관성형술을시행후직경 8 mm, 길이 40 mm의스텐트 (precise stent) 를삽입하였고 (Figure 4), 스텐트삽입후우측척추동맥으로부터의역행성혈류소견은관찰되지않았다 (Figure 5). 시술후환자는어지럼증과말더듬증은사라졌고양측상완동맥혈압도 130/80 mmhg로동일하게측정되었다. 시술한달후외래에서추적관찰에서도어지럼증과말더듬증세는더이상호소하지않았다. 고찰 일차의료에서환자로부터 혈압을잴때어느팔의혈압을재는것이좋아요? 혹은 양팔의혈압의차이가나는데왜이런현상이있나요? 라는질문을종종받게된다. 그러나임상에서의사는이에대한확실한답변을해주지못한채 여러차례번갈아가며측정하여높은쪽혈압을기준으로하세요. 혹은 " 양팔의혈압은대부분약간씩차이가있을수있으며, 수 가정의학회지 Vol. 30, No. 12 Dec

4 Won-Back Kim, et al: A Case of Successful Steal Syndrome Who Found Incidentally Significant Interarm Blood Pressure Difference 축기혈압이 20 mmhg 이상, 이완기혈압이 10 mmhg 이상차이가날때혈관해부학적이상이나대동맥축착를의심한다. 라는간단한대답만했는데이는기존의연구 6) 에의하여권유된것이다. 2007년 ESH-ESC Guidelines에서도처음진료실을방문하였을때는양팔의혈압을측정해야하며양팔의차이가나면말초혈관질환을의심할수있다고설명하고있다. 이와같이혈압을어느쪽이든높은쪽을기준으로한다는간단한설명은되어있지만양팔의혈압차를얼마까지정상으로보아야하는지에대한설명은없었다. 7) 양측의혈압의차는연속적인방법으로재었을때측정순서, 호흡주기및심리상태에따라정상에서도차이가날수있다는보고가 20세기초부터있어왔다. 수축기혈압이 10 mmhg 이상차이가나는경우는 19.6%, 20 mmhg 이상차이나는경우는 4.2%, 이완기혈압이 10 mmhg 이상차이가나는경우는 8.1% 로보고하였으나, 8) 양팔의혈압을동시에측정하였을경우정상에서는 5 mmhg 이하로약간의차이만을관찰할수있었다고보고하고있다. 9,10) 양팔의차이는혈압이높을수록, 비만할수록, 수축기혈압이높을수록더많이나타났다. 11) 그리고관상동맥질환환자 12) 등에서양팔의혈압차이가더많이나타났고또한, 만성신장질환환자에서도양팔의혈압차이가커질수록사망률이높았고, 13) 수축기혈압이 10 mmhg 이상차이가났을경우에는새로운심혈관계질환의발생률이높았으며생존기간도짧았다. 3) 따라서, 양팔의혈압을측정하여차이가심하면말초혈관질환을의심하여야한다. 14) 무증상말초혈관질환을조기발견하고자할때비침습적인방법인발목상완지수 (ABI) 를측정하는데, 이는발목의수축기혈압을상완의수축기혈압으로나눈값으로도플러검사라는특별한의료장비를필요로하는검사이다. 그러나양팔의혈압측정은진단을위해특별한장비를요구하지않아비용효과측면에서일차의료에도움이될수있다고하겠다. 15) 또한, 양팔의혈압을반드시측정해야하는이유는중년의연령층에서수축기혈압 2 mmhg의혈압하강만으로뇌졸중으로인한사망률을 10% 감소시킬수있고, 허혈성심장질환으로인한사망률을 7% 정도낮출수있는데, 16) 만약낮은쪽을기준으로환자의혈압상태를판단하게된다면고혈압의진단율이낮아지거나치료가부적절하게될소지가있기때문이다. 17) 빗장밑동맥협착증이있는경우혈관조영술과비교한결과양팔의수축기혈압의차이가 10 mmhg 이상을기준으로하였을때예민도 65%, 특이도 85% 였으며, 20 mmhg 이상을기준으로하였을때는예민도 35%, 특이도 94% 를나타내었다. 따라서일단양팔의수축기혈압의차가 10 mmhg 이상이나 오면빗장밑동맥협착증을의심해야한다. 18) 또한양팔의혈압차이가크게날수록협착정도가심해진다. 19) 빗장밑동맥혈관협착은일반인의경우는약 2%, 질병으로병원에다니는환자의경우는약 7% 의유병률을보이고, 이는흡연, 수축기혈압의정도, 낮은고밀도콜레스테롤과깊은연관성이있었으며, 20) 빗장밑협착증이있으면다른위험요인과관계없이심혈관계질환으로인한사망률이크게높아진다. 21) 빗장밑동맥도류증후군이란빗장밑동맥의폐쇄로인해반대측척추동맥에서동측척추동맥으로역행성혈류가형성되어뇌바닥동맥 (basilar artery) 혈류량이감소되어나타나는여러가지신경학적증상및환측팔의허혈성변화를나타나는질환을말한다. 빗장밑동맥도류증후군의가장흔한원인은죽상동맥경화증이고그외에도타카야수동맥염 (Takayasu s arteritis), 흉곽출구 (thoracic outlet) 에서빗장밑동맥의눌림, 외상, 혈전, 염증, 선천성기형, 수술등이원인이될수있다. 남자가여자보다많이발생하며좌측이우측보다빈도가 3배정도높다. 빗장밑동맥도류증후군의대부분은무증상이나증상을나타내는경우, 척추뇌기저부허혈로인한증상과상지허혈로인한증상으로나눌수있다. 동측상지허혈로인해나타나는증상으로는팔의간헐적파행, 피로, 감각이상, 마비등이있고척추뇌기저부허혈과관련되어나타나는증상으로는어지럼증이가장흔하고그외에조화운동불능, 불균형, 복시, 안구진탕, 적하발작, 반맹 (hemianopsia), 실신등이있다. 빗장밑동맥의기시부협착의경우는중추신경계증상이잘나타나고빗장밑동맥원위부협착의경우가팔의허혈증상이잘나타난다. 5) 확진은동맥조영술을통해빗장밑동맥의협착부위의확인과척추동맥을통해빗장밑동맥으로역류하는조영제의흐름을확인함으로가능하다. 그밖의방법으로양팔의혈압의차이가 mmhg 이상차이가나면전산화단층촬영을이용한 3차원혈관조영술이나자기공명영상혈관조영술을통해빗장밑동맥의폐색부위를확인하는방법이있다. 빗장밑도류증후군의치료방법은수술적방법과방사선중재시술법이있으며, 치료의목적은감소된빗장밑동맥의혈류량을증가시켜, 척추동맥의역류를방지하고, 팔의혈류량을증가시키는것이다. 수술적치료방법에는목동맥빗장밑동맥우회술, 겨드랑동맥겨드랑동맥우회술, 개흉을통한동맥내막절제술과대동맥궁빗장밑동맥우회술등이있다. 방사선중재시술법은혈관중재시술을이용한빗장밑동맥협착부위의풍선확장술과스텐트삽입술이있다. 지금까지국내에서는우회술을이용한사례보고들이있었다. 22,23) 방사선중재시술방법은간단한국소마취로이루어지며, 982 Vol. 30, No. 12 Dec 2009 Korean J Fam Med

5 김원백외 : 양팔의혈압차이로발견한빗장밑동맥도루증후군 (Subclavian Steal Syndrome) 환자증례 진단적으로확진을위한혈관조영술을시행하면서동시에중재시술을하므로재원기간을줄일수있을뿐아니라 90% 이상의높은치료성공률을보이고있다. 최근단순혈관확장술보다스텐트삽입술은추적관찰중재협착률이낮게보고되고있다. 24) 장기적으로살펴보았을때수술적우회술의개존률이 1년 100%, 3년 98%, 5년 96% 로스텐트삽입술의각각 93%, 78%, 70% 보다우수하다고보고하고있으나, 허혈성심장질환, 뇌혈관질환이동반되어있어수술적치료가어려운경우에는중재시술을통한치료가최적치료로추천되고있다. 25) 이상으로양팔의혈압을정확히측정하여, 그차이가 10 mmhg 이상이면일단말초혈관질환을의심하여야하며, 심혈관계질환이있는경우는양팔의차이가 5 mmhg 차이가나는경우는심혈관계질환위험인자를보다적극적으로교정하여야한다고생각되고, 추적혈압을잴때는가정에서나진료실에서높은팔의혈압을기준으로하여야한다. 빗장밑동맥의협착의경우에치료로우회수술을하는방법도있지만, 비교적간단하게요골동맥 (radial artery) 을통한경피적혈관성형술및스텐트삽입술을치료법으로고려해볼필요가있겠다. 요약 양팔의혈압은정상인에있어서도약간씩만차이가있을수있으나그차가심할수록동맥경화증으로인한빗장밑동맥의협착을비롯한말초혈관질환을시사하고, 심혈관계질환의이환율과사망률이높아진다. 빗장밑동맥도류증후군은말초동맥질환의일종으로빗장밑동맥의협착으로인하여나타난현상을의미하며, 가장흔한원인은동맥경화증이다. 증상은뇌기저부허혈증상과병변측의상지허혈증상으로나타내고, 치료는수술적방법과혈관중재시술을통하여혈류를재개한다. 저자들은힘든작업후에어지러움, 말이꼬이는증상을주소로내원한 42세남자환자에서양팔의수축기혈압이차이가 35 mmhg으로차이를보여검사한결과빗장밑동맥도류증후군을진단하고비교적간단하게요골동맥 (radial artery) 을통하여경피적혈관성형술로스텐트를삽입하여좋은결과를얻어문헌고찰과함께보고하는바이다. 중심단어 : 양팔혈압차 ; 빗장밑동맥도류증후군 ; 말초혈관질환 REFERENCES 1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003;289: Clark CE, Powell RJ. The differential blood pressure sign in general practice: prevalence and prognostic value. Fam Pract 2002;19: Clark CE, Campbell JL, Powell RJ. The interarm blood pressure difference as predictor of cardiovascular events in patients with hypertension in primary care: cohort study. J Hum Hypertens 2007;21: Igarashi Y, Chikamori T, Tomiyama H, Usui Y, Hida S, Tanaka H, et al. Clinical significance of inter-arm pressure difference and ankle-brachial pressure index in patients with suspected coronary artery disease. J Cardiol 2007;50: Pollard H, Rigby S, Moritz G, Lau C. Subclavian steal syndrome: a review. Australas Chiropr Osteopathy 1998;7: Petrie JC, O'Brien ET, Littler WA, de Swiet M. Recommendations on blood pressure measurement. Br Med J (Clin Res Ed) 1986;293: Mansia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al ESH-ESC Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European society of hypertension (ESH) and of the European society of cardiology (ESC). Blood Press 2007;16: Clark CE, Campbell JL, Evans PH, Millward A. Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review. J Hum Hypertens 2006;20: Kim HJ, Won CW, Ann ES, Jung JJ, Kim BS, Choi HR. Blood pressure difference between right and left arms of some college freshmen. J Korean Acad Fam Med 2003;24: Kim SJ, Jung IC, Lee BA, Woo KW, Lee SW, Hong YS. Assessment of disparity in the blood pressure of both arms. J Korean Soc Emerg Med 2003;14: Arnett DK, Tang W, Province MA, Oberman A, Ellison RC, Morgan D, et al. Interarm differences in seated systolic and diastolic blood pressure: the hypertension genetic epide miology 가정의학회지 Vol. 30, No. 12 Dec

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untitled 370 Minho Han. Subclavian Steal Syndrome Treated by Stent Insertion CASE REPORT Korean J Clin Lab Sci. 2018;50(3):370-374 https://doi.org/10.15324/kjcls.2018.50.3.370 pissn 1738-3544 eissn 2288-1662 Duplex