Focused Issue J Korean Diabetes 2019;20: Vol.20, No.1, 2019 ISSN 당뇨병환자에서말초혈관질환의중재시술및수술적치료 김상훈차

Size: px

Start display at page:

Download "Focused Issue J Korean Diabetes 2019;20: Vol.20, No.1, 2019 ISSN 당뇨병환자에서말초혈관질환의중재시술및수술적치료 김상훈차"

순창 담
5 years ago
Views:

1 J Korean Diabetes 2019;20:33-41 Vol.20, No.1, 2019 ISSN 김상훈차의과학대학교의과대학분당차병원심장내과 Interventional and Surgical Treatment of Peripheral Artery Disease in Diabetic Patients Sang Hoon Kim Division of Cardiology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea Abstract After diagnosis of peripheral artery disease in diabetic patients, revascularization can be considered in those who are not improved after guideline-directed medical therapy. Recently, more aggressive approaches with interventional treatment have been recommended. Before revascularization therapy, it is important to differentiate patients with claudication or critical limb ischemia, and the final goal and treatment modality of interventional treatments should be based on clinical diagnosis. For patients with claudication, the goal of revascularization is improvement of functional capacity or quality of life; however, in more severe forms of critical limb ischemia, the purpose of revascularization is limb salvage and ultimately saving patient s life. With improvement of vascular interventions, interventional treatment for peripheral artery disease is preferred, although surgical treatment might show better results than intervention in some cases. Keywords: Diabetes mellitus, Intervention, Peripheral arterial disease Corresponding author: Sang Hoon Kim Division of Cardiology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea, kimsang978@naver.com Received: Jan. 18, 2019; Accepted: Jan. 28, 2019 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2019 Korean Diabetes Association The Journal of Korean Diabetes 33

2 서론 당뇨병환자에서말초혈관질환진단후약물치료, 운동요법등의보존적치료에도불구하고간헐성파행 (intermittent claudication) 등의증상이호전되지않거나, 발에발생한상처가악화되어결국하지절단의위기에처하게되는중증하지허혈증 (critical limb ischemia, CLI) 등의경우중재시술혹은수술을통하여적극적인혈관개통 (revascularization) 치료를하는것으로최근치료방침이변화하고있다 [1,2]. 말초혈관질환환자에게중재시술이나수술등의적극적인치료여부를결정하는데있어환자의증상과임상양상을구분하는것이필요한데단순간헐성파행증만있는것인지조직괴사를동반한 CLI인지를구분하는것이치료의방침과목표를정하는데매우중요하다. 단순간헐성파행증의경우 5년내약 10~15% 의환자가 CLI로진행하므로 [3,4] 궁극적으로는사지의보존 (limb salvage) 이목적이되어야하나실제로는환자의운동능력향상이나삶의질향상이치료의주목표가되며, CLI의경우에는최대한사지의절단을피하게하는것이주목표가된다 [1]. 치료의목표를정한후에는환자의상태 ( 전신상태, 동반질환여부, 환자의보행가능여부, 신장기능, 환자의잔여기대여명등 ) 와사전검사 ( 초음파검사, computed tomography angiography, magnetic resonance angiography 등 ) 들을통해파악한환자혈관의해부학적상태및시술혹은수술의위험도나복잡성등을고려하여중재시술혹은수술을결정하게된다. 과거에는혈관우회로조성술 (bypass surgery) 이나혈관내죽종제거술 (surgical endarectomy) 등의수술적방법이주된치료로여겨져왔으나최근들어중재시술의술기와기구들이비약적으로발전하였고환자의편의성증대등을고려하여중재시술적치료가조금더선호되는경향이있다. 중재시술이나수술등의혈관재개통술을결정하고시행하는데있어또하나의중요한요소는환자와의소통이다. 재개통술에따라예상되는환자의위험이나그에따른이 득에대하여환자와사전에충분히논의되어야하며시행할재개통술방법의내구성 (durability) 등에대해서도환자에게충분한정보를제공하고토론의과정을거친후에재개통술을진행하는것또한향후치료순응도를높이고치료예후를호전시키는중요한과정이다 [1]. 본론 1. 재개통술의방법선택재개통술을시행하기로결정한경우중재시술을시행할지수술적방법을시행할지를결정하는여러가이드라인들이제시되고있으며 [1,2], 이가이드라인도여러새로운치료방법들의개발과임상연구들의결과에따라계속변화하고있어어떤방법을우선사용할지결정하는과정에는다각적인접근이필요하다. 그중가장많이알려져있고간단하여널리사용되는방법인 TransAtlantic InterSociety Consensus (TASC) classification [5] 은전체환자를가장간단한 A군부터가장복잡한 D군까지 4가지군으로분류하여 A~C군까지는중재시술적방법을우선적으로권장하고 D군에서는수술적방법을우선선택하도록한다. 다만최근수년사이중재시술적치료방법의비약적인발전에힘입어 D군에해당하는많은환자에서도경험이충분한중재시술의사라면중재시술적치료방법을우선선택하고중재시술이실패할경우수술적치료방법을고려하도록하는많은임상결과및전문가의견이제시되어실제임상에서도적용되고있다. 또한일부환자군에서는좀더나은장기적치료성적을위하여한명의환자에서혈관의부위를나누어중재시술적치료와수술적치료를동시에시행하는, 이른바하이브리드치료 (hybrid treatment) 도많이시행되고있다 (Fig. 1) [5]. 34

3 김상훈 Fig. 1. Management of patients with intermittent claudication (2017 European Society of Cardiology [ESC] guideline). Adapted from the article of 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases (Eur Heart J 2018;39: ) [2] with original copyright holder s permission. CFA, common femoral artery; SFA, superficial femoral artery. 2. 파행증에대한재개통술 (revascularization for claudication) 1) 중재시술을통한파행증의치료파행증을치료하는데쓰이는중재시술적방법으로는크게풍선성형술 (balloon angioplasty), 스텐트 (stent), 죽종 절제술 (atherectomy) 등이있고발전된형태인약물방출스텐트나풍선, 칼날풍선 (cutting balloon) 및그래프트스텐트 (graft stent) 등도있다. 중재시술적방법은병변의상태 ( 해부학적위치나형태, 병변의길이, 칼슘의정도등 ) 와시술자의경험등에따라달라지게된다. 본글에서자세히다루지는않겠지만어떠한병변에어느종류의중재시술적 35

4 방법을사용하느냐하는문제는대단히복잡하고중요하다. 일반적으로혈역학적인혈류감소가동반되어있거나조영술상 50~75% 정도의협착이관찰되는병변에대하여중재시술적치료를시행한다 [6,7]. 각각의치료방법과관련하여단독혹은여러치료방법들을병합한형태의다양한임상연구가진행되었고환자군및치료방법의조합등에따라다양한결과를보여주고있다 [8-15]. 일반적으로심장에서가까운부위혈관의치료성적이심장에서먼부위혈관의치료성적보다개선된경향을보이고, 같은부위라도해부학적으로병변의길이가좀더긴혈관, 단순히좁아진혈관보다는완전히막혀있던혈관, 많은칼슘을동반한혈관등에서조금더나쁜장기적성적을보이는경향이있다 [1,2]. 그외에도흡연, 신장질환이동반된환자에서더나쁜치료성적을보이며, 특히당뇨병을동반한환자군에서의장단기중재시술의결과는일관적으로당뇨병을동반하지않은환자군에비해서나쁜경향을보이므로당뇨병환자에서중재시술을시행할경우더적극적인약물치료와관리가필요하다. 2) 수술을통한파행증의치료중재시술이개발되기이전부터시행되던수술적치료는파행증의치료에있어효과적이고삶의질을개선시키는충분한효과가있다. 하지만다른치료방법 ( 약물치료, 운동치료및중재시술치료 ) 들의비약적인발전에따라그입지가조금씩줄어들고있는실정이다 [12,16-18]. 하지만여전히일부병변에서는수술적치료가중재시술적치료와비교하여증상의호전이나장기적인혈관개통의유지측면에서조금더나은성적을보이므로, 수술적치료에따른수술전후합병증의위험도가높은환자가아니라면일부병변에대해서는수술적치료가환자에게좀더유리한치료방법이될수있다 [19-21]. 따라서전술한바와같이각각의환자에대해치료목표를설정하고수술전후환자의위험도와장기적인치료성적등을고려하여필요에따라수술적치료방법을선택하는것이중요하다. 파행환자에게있어병변호발부위인대퇴동맥 (superficial femoral artery) 및오금 동맥 (popliteal artery) 에서가장많이시행되는수술인혈관우회로조성술의장기성적은중재시술과비교하여도일부환자군에서는아직까지도더나은성적을보이고있어많이시행되고있으며, 일반적으로자가정맥 (autologous vein) 을사용하여시행하는우회로술이인조혈관그래프트 (prosthetic graft) 에비하여더나은성적을보이고있어수술적치료를계획할경우이에대한고려도필요하다 [22,23]. 3. 중증하지허혈증에대한재개통술 (revascularization for critical limb ischemia) CLI가발생한환자는매우높은사지절단의위험을가지며또한동반된심혈관질환으로인하여높은사망률을보이므로단순간헐성파행증보다매우주의깊은관심과치료가필요하다. 전술한바와같이 CLI 환자의사망률이매우높으므로 CLI 환자에서치료의주된목표는신체조직손실을최소화하여발의기능적역할을최대한살려냄으로써사지를보존하는것이된다. 따라서중재시술및수술등의재개통술뿐만아니라약물치료등으로전반적인심혈관질환에대한치료를하는것이매우중요하다 (Fig. 2) [1,2]. 1) 중재시술을통한중증하지허혈증의치료 CLI에서중재시술의목표는최소 1개이상혈관의혈류를유지함으로써상처부위에혈액이공급되게하여허혈성통증을경감시키고상처의치유를도와서궁극적으로는기능적으로사용가능한하지를유지시켜주는것이다. 관련하여가장유명한연구중하나인 Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) 연구는중재시술적치료를수술적치료와비교한연구로서중재시술방법으로단순풍선성형술만을사용하였고수술적치료와동등한정도의하지보존생존 (amputation-free survival) 을보였다 [24,25]. 그외에도다양한임상연구들이진행중에있으며최근들어무릎아래혈관의치료에서는수술적치료보다중재시술이조금더나은성적을보여주고있어일차치료로 36

5 김상훈 Fig. 2. Management of critical limb ischemia (2017 European Society of Cardiology [ESC] guideline). Adapted from the article of 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases (Eur Heart J 2018;39: ) [2] with original copyright holder s permission. EVT, endovascular therapy; GSV, great saphenous vein. 37

6 사용되고있다 [26,27]. 최근에는 angiosome이라는개념이도입되어널리사용되고있는데이는잘낫고있지않는상처부위에혈류를직접공급하는혈관을개통하여상처치료가더잘되도록하겠다는혈관개통술의개념으로이와관련한여러가지연구결과들이보고되었다 [28,29]. 제시된이론자체가합리적으로생각되어많은중재시술을시행하는의사들이도입하여시행하고있으나아직까지무작위연구를통하여 angiosome 개념의혈관개통술이더우월하다는것을입증하지는못하고있어추가적인연구결과가필요할것으로생각된다. 또한무릎아래혈관의치료에있어서약물풍선을이용한치료나죽종절제술을이용한치료혹은두가지를병합한치료방법들에대한연구가진행되었으나뚜렷한치료성적의호전을보이지는못하고있어아직까지는단순풍선성형술을통한무릎아래혈관의개통술이일차치료로인정되고있다. 2) 수술을통한중증하지허혈증의치료전술한바와같이아직까지는무릎아래혈관의치료에있어수술적치료가중재시술적치료에비해치료성적의호전을보이지는못하고있어일차적인치료로사용되지는않고있다. 하지만중재시술로재개통에실패한무릎아래혈관의문제나무릎위혹은오금동맥을침범한혈관문제로인한 CLI 등에서자가정맥을이용한혈관우회로조성술이치료방법의하나로사용될수있다. 결론 당뇨병환자에게서중재시술혹은수술등을통한말초혈관질환의치료는기술의발전과함께그성적이지속적으로향상되고있다. 가이드라인에근거한약물치료및운동치료등에도호전을보이지않는환자에게적극적으로혈관재개통술을고려하는것이필요하며, 혈관재개통술의방법을정하는데있어서는 CLI와같은심각한질환의동반여부파악과같은말초혈관질환에대한정확한상태파악 이우선되어야하며그에따른치료의목표를정하고환자와소통의과정을거쳐치료의방침을정하고치료를시행하여야한다. REFERENCES 1. Writing Committee Members, Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME; ACC/AHA Task Force Members, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Pressler SJ, Wijeysundera DN AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Vasc Med 2017;22:NP Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I; ESC Scientific Document Group ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesendorsed by: the European Stroke Organization (ESO) the task force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018;39:

7 김상훈 3. Jelnes R, Gaardsting O, Hougaard Jensen K, Baekgaard N, Tønnesen KH, Schroeder T. Fate in intermittent claudication: outcome and risk factors. Br Med J (Clin Res Ed) 1986;293: Leng GC, Lee AJ, Fowkes FG, Whiteman M, Dunbar J, Housley E, Ruckley CV. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 1996;25: TASC Steering Committee, Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II). Vasc Med 2015;20: Udoff EJ, Barth KH, Harrington DP, Kaufman SL, White RI. Hemodynamic significance of iliac artery stenosis: pressure measurements during angiography. Radiology 1979;132: Tetteroo E, van Engelen AD, Spithoven JH, Tielbeek AV, van der Graaf Y, Mali WP. Stent placement after iliac angioplasty: comparison of hemodynamic and angiographic criteria. Dutch Iliac Stent Trial Study Group. Radiology 1996;201: Vemulapalli S, Dolor RJ, Hasselblad V, Subherwal S, Schmit KM, Heidenfelder BL, Patel MR, Schuyler Jones W. Comparative effectiveness of medical therapy, supervised exercise, and revascularization for patients with intermittent claudication: a network meta-analysis. Clin Cardiol 2015;38: Murphy TP, Cutlip DE, Regensteiner JG, Mohler ER 3rd, Cohen DJ, Reynolds MR, Massaro JM, Lewis BA, Cerezo J, Oldenburg NC, Thum CC, Jaff MR, Comerota AJ, Steffes MW, Abrahamsen IH, Goldberg S, Hirsch AT. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol 2015;65: Murphy TP, Cutlip DE, Regensteiner JG, Mohler ER, Cohen DJ, Reynolds MR, Massaro JM, Lewis BA, Cerezo J, Oldenburg NC, Thum CC, Goldberg S, Jaff MR, Steffes MW, Comerota AJ, Ehrman J, Treat-Jacobson D, Walsh ME, Collins T, Badenhop DT, Bronas U, Hirsch AT; CLEVER Study Investigators. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation 2012;125: Nordanstig J, Taft C, Hensäter M, Perlander A, Osterberg K, Jivegård L. Improved quality of life after 1 year with an invasive versus a noninvasive treatment strategy in claudicants: one-year results of the Invasive Revascularization or Not in Intermittent Claudication (IRONIC) Trial. Circulation 2014;130: Malgor RD, Alahdab F, Elraiyah TA, Rizvi AZ, Lane MA, Prokop LJ, Phung OJ, Farah W, Montori VM, Conte MS, Murad MH. A systematic review of treatment of intermittent claudication in the lower extremities. J Vasc Surg 2015;61:54S-73S. 13. Spronk S, Bosch JL, den Hoed PT, Veen HF, Pattynama PM, Hunink MG. Intermittent claudication: clinical effectiveness of endovascular revascularization versus supervised hospital-based exercise training--randomized controlled trial. Radiology 2009;250: Greenhalgh RM, Belch JJ, Brown LC, Gaines PA, Gao L, Reise JA, Thompson SG; Mimic Trial Participants. The adjuvant benefit of angioplasty in patients with mild to moderate intermittent claudication (MIMIC) managed 39

8 by supervised exercise, smoking cessation advice and best medical therapy: results from two randomised trials for stenotic femoropopliteal and aortoiliac arterial disease. Eur J Vasc Endovasc Surg 2008;36: Nordanstig J, Gelin J, Hensäter M, Taft C, Österberg K, Jivegård L. Walking performance and health-related quality of life after surgical or endovascular invasive versus non-invasive treatment for intermittent claudication--a prospective randomised trial. Eur J Vasc Endovasc Surg 2011;42: Jones WS, Schmit KM, Vemulapalli S, Subherwal S, Patel MR, Hasselblad V, Heidenfelder BL, Chobot MM, Posey R, Wing L, Sanders GD, Dolor RJ. Treatment strategies for patients with peripheral artery disease. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 May. Report No.: 13-EHC090-EF. 17. Antoniou GA, Chalmers N, Georgiadis GS, Lazarides MK, Antoniou SA, Serracino-Inglott F, Smyth JV, Murray D. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg 2013;57: Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev 2008;(2):CD Aihara H, Soga Y, Mii S, Okazaki J, Yamaoka T, Kamoi D, Shintani Y, Ishikawa T; RECANALISE Registry Investigators. Comparison of long-term outcome after endovascular therapy versus bypass surgery in claudication patients with Trans-Atlantic Inter-Society Consensus-II C and D femoropopliteal disease. Circ J 2014;78: Sachwani GR, Hans SS, Khoury MD, King TF, Mitsuya M, Rizk YS, Zachwieja JA, Sayed L. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg 2013;57: Siracuse JJ, Gill HL, Schneider DB, Graham AR, Connolly PH, Jones DW, Meltzer AJ. Assessing the perioperative safety of common femoral endarterectomy in the endovascular era. Vasc Endovascular Surg 2014;48: Pereira CE, Albers M, Romiti M, Brochado-Neto FC, Pereira CA. Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency. J Vasc Surg 2006;44: Twine CP, McLain AD. Graft type for femoropopliteal bypass surgery. Cochrane Database Syst Rev 2010;(5):CD Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366: Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Raab G, Ruckley CV. Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial. Health Technol Assess 2010;14:1-210, iii-iv. 26. Menard MT, Farber A. The BEST-CLI trial: a multidisciplinary effort to assess whether surgical or endovascular therapy is better for patients with critical limb ischemia. Semin Vasc Surg 2014;27: Menard MT, Farber A, Assmann SF, Choudhry NK, Conte MS, Creager MA, Dake MD, Jaff MR, Kaufman JA, Powell RJ, Reid DM, Siami FS, Sopko G, White CJ, Rosenfield K. Design and rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am 40

9 김상훈 Heart Assoc 2016;5:e Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN. Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg 2009;23: Acín F, Varela C, López de Maturana I, de Haro J, Bleda S, Rodriguez-Padilla J. Results of infrapopliteal endovascular procedures performed in diabetic patients with critical limb ischemia and tissue loss from the perspective of an angiosome-oriented revascularization strategy. Int J Vasc Med 2014;2014:

A 617

A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R