Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 대상과방법 환자군 2008 년 10 월부터 2010 년 8 월까지일률적으로 tapered stent (PROSTE GE TM RX Tapered, ev3 Inc., Plymouth, MN, USA) 를이용하

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1 Original Article pissn J Korean Soc Radiol 2011;65(4): Preliminary Report of Carotid Artery Stenting Using a Tapered Stent 1 Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 1 Chang Woo Jeong, MD 1, Dong Hyun Kim, MD 1, Seong Hwan Ahn, MD 2, Dong Uk Kim, MD 2, Seung Jeong Hong, MD 1, Young Suk Kim, MD 1, Joo Nam Byun, MD 1, Jae Hee Oh, MD 1 Departments of 1 Radiology, 2 Neurology, Chosun University College of Medicine, Gwangju, Korea Purpose: To analyze the results of carotid artery stenting using a tapered stent and to evaluate the effectiveness of the tapered stent compared to previously reported studies using non-tapered stents. Materials and Methods: From October 2008 to August 2010, elective carotid artery stenting using a tapered stent was attempted in 39 lesions from 36 consecutive patients. Post-procedural complications were evaluated by neurologic symptoms and magnetic resonance imaging. Restenosis or occlusion was evaluated by carotid Doppler ultrasound and computerized tomography with angiography. Newly developed neurologic symptoms were evaluated clinically. Results: The self-expandable tapered stent was placed across the carotid artery stenosis. A total stroke was noted in 3 patients, while a major stroke was noted in 1 patient. On diffusion weighted imaging, new lesions were observed in 15 patients, but 13 patients were clinically silent. Follow-up imaging studies were performed in the 13 clinically silent lesions, and no evidence of restenosis or occlusion was found any of the 13 lesions. During clinical follow-up in 34 lesions from 31 patients, there were newly developed neurological symptoms in only 1 patient. Conclusion: Carotid artery stenting using a tapered stent may be safe and useful for the treatment of carotid artery stenosis. Index terms Carotid Arteries Carotid Artery Stenosis Stents Transluminal Angioplasty Received May 17, 2011; Accepted August 15, 2011 Corresponding author: Dong Hyun Kim, MD Department of Radiology, Chosun University College of Medicine, 588 Seoseok-dong, Dong-gu, Gwangju , Korea. Tel Fax radkdh@chosun.ac.kr Copyrights 2011 The Korean Society of Radiology 서론 경동맥스텐트설치술 (CAS) 은중증의경동맥협착을가진환자에서경동맥내막절제술 (CEA) 을대신하여뇌졸중을줄일수있는치료법이다 (1-3). 경동맥스텐트설치술의결과는시술자의경험, 판단및기구등에의해영향을받으며환자의위험인자, 플라크의특성또한영향을미친다 (4-6). 대부분의경동맥스텐트설치술은총경동맥과내경동맥사이에서이루어지고있으며, non-tapered stent 를사용한경동맥스텐트설치술은총경동맥과내경동맥의직경의차이에의해내경동맥에더큰직경의스텐트삽입 (stent oversizing) 이발생할수있다. 일부연구에서신생내막의증식을유발하는요인으로더큰직경의스텐트삽입보다는스텐트를삽입하는동안의혈관손상을주요인으로보고하였으나 (7, 8), Wallstent 를사용하여경동맥스텐트설치술을시행한한보고에서는혈관직경의차이 가 delayed stent shortening 을유발할수있으며, 이는재협착의한요인이될수있다고보고하기도하였다 (9). Tapered stent 는해부학적으로적합한형태를갖추고있어이혈관의직경의차이에따른더큰직경의스텐트삽입에의한효과를줄일수있으며, 장기적인동맥벽면에전달되는반지름방향의힘 (chronic outward radial force), 목움직임시에발생하는기계적스트레스 (mechanical stress) 와이로인한 strut migration 을줄일수있다는판단하에최근사용이증가하고있으나이에대한정확한연구는아직부족한상황이다 (10). 이에본연구의목적은내경동맥팽대부에중증의협착을가진환자에서 tapered stent 를이용한치료결과를분석하고시술후발생한합병증과추적관찰을통해재협착및폐쇄, 임상적으로무증상을보인기간에대해분석해보고자하였으며, 기존에보고된연구를바탕으로 non-tapered stent 의치료성적과비교해보고자하였다. submit.radiology.or.kr 대한영상의학회지 2011;65(4):

2 Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 대상과방법 환자군 2008 년 10 월부터 2010 년 8 월까지일률적으로 tapered stent (PROSTE GE TM RX Tapered, ev3 Inc., Plymouth, MN, USA) 를이용하여경동맥팽대부에스텐트설치술을시행한 36 명의 환자에서 39 개병변을후향적연구방법으로분석하였다. 환자 는남자가 30 명, 여자가 6 명이었으며, 평균나이는 67.4 세 (47~80 세 ) 였다. North American Symptomatic Carotid Endarterectomy Trial ( 이하 NASCET) criteria (11) 에따른평가에 서 29 예가 70% 이상의협착이있었으며, 10 예는증상을동반 한 50% 이상의내경동맥팽대부의협착이있었다. 6 명의환자 는반대편경동맥이이미폐쇄되었던환자였다. 1 명의환자는스 텐트설치술시행후반대편경동맥에경동맥내막절제술을시 행하였다 (Table 1). 시술전평가 모든환자는시술전에신경과의사에게신경학적검사를받 았으며, 혈관촬영술을포함하는전산화단층촬영 (CT angiography) 및자기공명영상 (MR angiography) 을시행하였다. 이 후정확한협착범위와두개강외동맥과두개강내동맥에대한 평가를위해대퇴동맥경유뇌혈관조영술 (transfemoral cere- Table 1. Patient Demographic Characteristics Patient Characteristics No. of Patient Total no. of patient (lesions) 36 (39) Age range (yr) (mean age) (67.16) M : F 30 : 6 Degree of carotid stenosis (mean) 54-94% (67.4%) 50-70% 10 > 70% 29 High risk criteria Contralateral carotid stenosis < 50% % % 6 100% (complete occlusion) 6 Previous neck irradiation 0 Recent MI (within 3 month) 2 Comobidities Coronary artery disease 3 Hypertension 24 Diabetes 9 Smoking 12 Hypercholesterolemia 25 Renal insufficiency 3 bral angiography) 을시행하였으며, NASCET criteria 에따라협착의정도를평가하였다. 전처치및스텐트설치술환자는최소시술 7일전부터 aspirin 100 mg과 clopidogrel 75 mg을복용하였다. 모든시술은국소마취하에시행하였으며, 시술중환자의동맥산소포화도와혈압을적절히감시하였다. 환자의활성혈액응고시간 (activated clotting time) 을 250~300 초정도로유지하기위해 hepatin 을일시주사로 3,000 IU 를투여한후시간당 1,000 IU 를추가로정맥주사하였다. 8F 유도관 (Guider Softip TM XF, Boston Scientific Corp., Maple Grove, MN, USA) 을총경동맥에위치시킨후 Filterwire (FilterWire EZ, Boston Scientific Corp., Maple Grove, MN, USA) 와 delivery sheath 를협착부위를넘어서까지진행하고 sheath 를제거하고 Filterwire 를설치하였으며, Filterwire 를따라서스텐트를진행하여외경동맥의기시부를가로질러총경동맥분지부에설치하였다. 스텐트는자가팽창성 (self-expandable) 의 tapered stent 를사용하였다. 스텐트설치후풍선카테터 (Ultra-soft TM SV MONORAIL TM, Boston Scientific Corp., Maple Grove, MN, USA) 를이용하여규정압력에따라풍선확장술을시행하였으며, 경동맥확장에의한서맥, 일시적인뇌혈류차단에의한경련등에유의하였다. 스텐트설치가끝나면 Filterwire 는 retrieval sheath 를이용해제거하였다. 20 분후에뇌혈관조영술을시행하여잔여협착 (residual stenosis) 여부와색전증에의한뇌혈관폐쇄여부를확인하였다. 시술후평가스텐트설치술직후모든환자는신경학적검사를시행하였다. 중증뇌졸중 (major stroke) 은 24시간이상지속하는신경학적결손이있으며 National Institutes of Health Stroke Scale (NIHSS)(12) 이 3점이상증가한경우로정의하였으며, 신경학적결손이 24시간이상지속하나 NIHSS 가 3점이상증가하지않은경우는경증뇌졸중 (minor stroke) 으로, 신경학적결손이 24시간이내에완전히회복된경우는일과성허혈증 (transient ischemic attack) 으로정의하였다. 모든환자는시술 3일이내에 T2 강조영상 (T2 weighted image), 액체감약반전회복영상 (fluid-attenuated inversion recovery: FLAIR) 그리고확산강조영상 (diffusion weighted image) 을포함하는뇌자기공명영상을시행하여시술전영상과비교하여새롭게발생한병변의유무를확인하였으며, 이는색전병변으로정의하였다. 총 12명환자에서 13개병변에대해영상검사를통한추적관찰을시행하였으며, 11예에서경동맥도플러초음파 (carotid doppler ul- 366 대한영상의학회지 2011;65(4): submit.radiology.or.kr

정창우외 trasound; DUS) 를통해, 2예에서는혈관촬영술을포함하는전산화단층촬영을통해재협착및폐쇄에대한평가를시행하였다. 50% 이상의협착을재협착으로정의하였다.

결과 모든 39 예에서일률적으로자가팽창성의 tapered stent 를이 용하여총경동맥분지부에설치하였다. 총 3예에서뇌졸중이발생하였으며, 1예에서중증뇌졸중이발생하였다.

5일후퇴원시증상호전을보였으며 19일후복부대동맥류에대한수술을시행하였다. 수술 4일후양측전하소뇌동맥영역및반대측중뇌동맥에경색이발생하였다 (Fig. 1).

In a 67-year-old woman patient, MRI shows focal stenosis at the right carotid bulb and complete occlusion

3D digital subtraction angiography before the procedure shows focal stenosis with ulcerated plaque at the

Post-procedural diffusion weighted-mr image shows newly developed high signal intensity in left middle

3 정창우외 trasound; DUS) 를통해, 2예에서는혈관촬영술을포함하는전산화단층촬영을통해재협착및폐쇄에대한평가를시행하였다. 50% 이상의협착을재협착으로정의하였다. 31명의환자에서 34개의병변에대한임상적인추적관찰을시행하여새롭게발생한신경학적증상유무를평가하였다. 결과 모든 39 예에서일률적으로자가팽창성의 tapered stent 를이 용하여총경동맥분지부에설치하였다. 총 3예에서뇌졸중이발생하였으며, 1예에서중증뇌졸중이발생하였다. 이환자는반대쪽경동맥의완전폐쇄및반대측중뇌동맥영역의경색이있었던환자였다. 스텐트삽입술후 NIHSS 가 3점이상증가하였으며, 1일후시행한확산강조영상에서반대측중뇌동맥영역에새롭게발생한뇌경색병변이관찰되었다. 5일후퇴원시증상호전을보였으며 19일후복부대동맥류에대한수술을시행하였다. 수술 4일후양측전하소뇌동맥영역및반대측중뇌동맥에경색이발생하였다 (Fig. 1). 경증뇌졸중이발생한 2예중 A B C D E F Fig. 1. In a 67-year-old woman patient, MRI shows focal stenosis at the right carotid bulb and complete occlusion of a left internal carotid artery (arrow) (A). 3D digital subtraction angiography before the procedure shows focal stenosis with ulcerated plaque at the right carotid bulb (arrow) (B). Post-procedural angiography shows well conformable stent structure (C). Post-procedural diffusion weighted-mr image shows newly developed high signal intensity in left middle cerebral artery territory (D). Surgical repair of abdominal aortic aneurysm was performed at 1 month after carotid artery stenting. Post-operative diffusion weighted-mr images shows high signal intensity in anterior inferior cerebellar artery territory, both and left middle cerebral artery territory (E, F). submit.radiology.or.kr 대한영상의학회지 2011;65(4):

Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 1 예는동측에점모양의작은고신호강도가보였으며, 이환 자는고혈압, 당뇨및흡연등의위험인자를가지고있던환자 로좌측반맹과촉각적일측무시 (tactile neglect) 의신경학적 증상이발생하였다. 다른 1 예는확산강조자기공명영상에서색 전병변이관찰되지않았다.

4 Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 1 예는동측에점모양의작은고신호강도가보였으며, 이환 자는고혈압, 당뇨및흡연등의위험인자를가지고있던환자 로좌측반맹과촉각적일측무시 (tactile neglect) 의신경학적 증상이발생하였다. 다른 1 예는확산강조자기공명영상에서색 전병변이관찰되지않았다. 2 예모두 5 일이내에신경학적증 상이완전소실되었으며퇴원시새롭게발생한신경학적증상 은보이지않았다 (Table 2). 시술후시행한확산강조자기공명영상에서 15 예에서술전 영상에서는보이지않던새로운색전병변이관찰되었으며, 이 중 13 예에서는점모양의작은고신호강도가보였으나임상증 상은없었다. 증상이있었던 2 예중한명은중증뇌졸중이발 생한환자였으며, 다른한명은경증뇌졸중이발생하였다 (Fig. 2)(Table 3). Table 2. The Results of Carotid Artery Stenting Results No. (%) Death 0 (0) Total stroke 3 (7.7) Minor stroke 2 (5.1) Major stroke 1 (2.6) Total TIA 0 (0) Note.-TIA = transient ischemic attack Table 3. Embolic Lesions New lesions on DWI (%) 15 (38.5) Symptomatic (%) 2 (5.1) Asymptomatic (%) 13 (33.3) Note.-DWI = diffusion weighted image 총 12명에서 13개의병변에대해영상검사를통한추적관찰을시행하였으며 11예에서경동맥도플러초음파, 2예에서는혈관촬영술을포함하는전산화단층촬영을이용해추적검사를시행하였다. 평균추적관찰기간은 315 일 (2~552 일 ) 이었으며, 13예모두에서재협착및폐쇄는없었다 (Fig. 3). 또한 31명환자에서 34개의병변에대해임상적으로추적관찰을시행하였다. 평균추적관찰기간은 310 일 (12~777 일 ) 이었으며, 1예에서신경학적증상이발생하였다. 이환자는퇴원시 NIHSS 11점에서 16일후 12점으로증가하였으며이후추적관찰에서삼킴곤란, 명칭실어증 (anomia) 의증상이발생하였다. 그외 30명의환자에서는추적관찰기간중새롭게발생한신경학적증상이관찰되지않았다 (Table 4). 고찰 경동맥내막절제술은 NASCET 가그효용성을입증한이후로두개강외경동맥폐쇄성질환에대한표준치료법으로알려졌다. 하지만 CAVATAS (3) 는경동맥내막절제술과경동맥스텐트설치술이시술과연관된뇌졸중이나사망위험도에서유의한차이가없음을보고하였으며, SAPPHIRE (1) 는시술과연관된뇌졸중이나사망위험도를경동맥내막절제술과경동맥스텐트설치술에서각각 7.3% 와 4.4% 로보고하는등최근여러연구에서경동맥스텐트설치술은경동맥내막절제술을대체할수있는적합한치료로부각되고있다. 경동맥스텐트설치술시고려할사항으로시술과연관된합 A B Fig. 2. Diffusion weighted-mr image of a 69-year-old man with severe stenosis of right carotid artery. A, B. Compared with pre-procedural image (A), post-procedural diffusion weighted-mr image (B) shows high signal intensity in right parietal lobe (arrow), the patient had neurologic symptoms such as left hemianopsia and left tactile neglect, but the neurological symptoms completely disappeared within 5 days. 368 대한영상의학회지 2011;65(4): submit.radiology.or.kr

stenosis of carotid artery (C, D, E). Computerized tomography with angiography (A, B) and carotid Doppler ultrasound (C, D, E) show no restenosis.

스텐트삽입후재협착의발생기전은탄성반동 (elastic recoiling), 동맥재형성 (arterial remodeling) 및신생내막의증식 (neointimal hyperplasia) 으로알려져있으며, 대부분혈관평활근세포 (smooth muscle cell;

자가팽창성 non-taped stent 를이용하여내경동맥팽대부에스텐트를삽입하는경우총경동맥의직경에맞추어삽입할스텐트의직경을결정하게되며스텐트삽입후내경동맥에서스텐트가 self-taper 되게된다.

이에대하여관상동맥성혈술과관련하여많은연구가보고되었는데이러한작은직경의혈관에서는스텐트내혈전및급성폐쇄를예방하기위해스텐트과팽 Table 4. Follow-Up Examination Imaging F/U Total no.

5 정창우외 A B C D E Fig. 3. Post-procedural follow-up studies of a 59-year-old man with severe stenosis of left carotid artery (A, B) and a 69-year-old man with severe stenosis of carotid artery (C, D, E). Computerized tomography with angiography (A, B) and carotid Doppler ultrasound (C, D, E) show no restenosis. 병증뿐만아니라스텐트설치술후발생하는재협착에대한문제가있다. 스텐트삽입후재협착의발생기전은탄성반동 (elastic recoiling), 동맥재형성 (arterial remodeling) 및신생내막의증식 (neointimal hyperplasia) 으로알려져있으며, 대부분혈관평활근세포 (smooth muscle cell; SMC) 에의한신생내막의증식에의한다 (13-15). 신생내막의증식을유발하는요인으로는혈관성형술에의한기계적신전, stent struts 혹은스텐트를삽입하는동안의혈관손상이알려져있다 (16-18). 자가팽창성 non-taped stent 를이용하여내경동맥팽대부에스텐트를삽입하는경우총경동맥의직경에맞추어삽입할스텐트의직경을결정하게되며스텐트삽입후내경동맥에서스텐트가 self-taper 되게된다. 하지만이과정에서총경동맥과내경동맥의직경차에의해내경동맥에는더큰직경의스텐트가삽입되게되며이때혈관벽에지속적으로힘 (wall stress force) 이작용하게된다. 이에대하여관상동맥성혈술과관련하여많은연구가보고되었는데이러한작은직경의혈관에서는스텐트내혈전및급성폐쇄를예방하기위해스텐트과팽 Table 4. Follow-Up Examination Imaging F/U Total no. of patients (lesions) 12 (13) CT angiography 2 (2) Carotid doppler ultrasound 10 (11) Period (mean) (days) (315) Restenosis or occlusion (%) 0 (0%) Clinical F/U Total no. of patients (lesions) 31 (34) Period (mean) (days) (310) No. of patients with newly developed symptoms (%) 1 (2.9) 창및과도한혈관성형술을시행하게된다. 하지만경동맥은 큰직경의혈관이며현재는자가팽창성의스텐트를사용하기 때문에과도한혈관성형술을시행하지않는다. 따라서혈관의 과팽창에따른내막손상에의한부정적인효과보다는스텐트 삽입중에발생하는혈관벽의손상이더중요한인자로생각되 고있다 (7, 8). Non-tapered stent 는삽입중에더큰직경의 스텐트에의한내탄성막 (internal elastic lamina) 의분절에의 submit.radiology.or.kr 대한영상의학회지 2011;65(4):

6 Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 Table 5. Previously Published Studies of Carotid Artery Stenting References No. of Patients Patient Data No. of CAS Stenosis (%) Mortality Rate (%) Results Major Stroke (%) Minor Stroke (%) Restenosis (%) Roubin et al. (2) Yadav (1) > CAVATAS (3) > SAPPHIRE (1) > Brown et al. (10) Nontapered , asymptomatic or 50, symptomatic Tapered , asymptomatic or 50, symptomatic Our study Tapered , asymptomatic or 50, symptomatic Note.-CAS = carotid artery stenting (Total stroke) (Total stroke) 해내경동맥의내막에손상을줄가능성이있으나이기전에대한정확한연구는아직발표되지않았다. 경동맥스텐트설치술에서재협착에대한연구는아직정확히보고되지않았으며, 보고된연구에따라 1~24.5% 까지다양하게보고되고있다 (19-22). 이는연구에따라서재협착을평가하기위한도플러초음파의혈류속도에대한기준이다르며, 또한재협착의기준을 50% 이상, 혹은 80% 이상으로정의하는등재협착의기준을정의하는데어려움이있기때문으로생각된다 (6, 23, 24). Non-tapered stent 와 tapered stent 를비교한한연구에서는추적관찰시재협착률을각각 2.6% 와 0% 로보고하기도하는등 (10) 장기결과에서좋은결과를보일수있음을시사하였으나 tapered stent 에대한연구는아직많이보고되지않은상태이다. 본연구에서는총 39개병변에대해시술을시행한결과중증뇌졸중과경증뇌졸중이각각 2.6% 와 5.1% 로이전에보고된연구와큰차이가없었다. 중증뇌경색이발생한환자는이미반대측경동맥의완전폐쇄및중뇌동맥영역에경색이있었으며스텐트삽입술시행후전신마취하에복부대동맥류에대한수술을시행받았다. 이환자에서발생한중증뇌졸중은스텐트삽입술후의과관류증후군 (25) 과전신마취에따른저혈압, 장기간의수술시간, 저체온, 수술중수혈에의한헤마토크리트상승 (26) 등에의한복합적인원인이작용했을것으로생각된다. 13예에서시행한영상검사를통한추적관찰에서모두재협착이없었으며이는 tapered stent 를이용한연구와비교해동일한결과를보였다 (10)(Table 5). 임상적인추적관찰기간중새롭게발생한신경학적증상이 1명의환자에서발생하였으나이환자는내원시 NIHSS 12점으로좌측중뇌동맥영역에광범위한뇌경색이있었던환자로시술후퇴원시 NIHSS 11점으로증상이호전된후 16일뒤에시행한신경학적검사에서 NIHSS 12점으로증가하였으며, 이후추적관찰에서삼킴곤란, 명칭실어증 (anomia) 의증상이발생하였다. 이는시술후새롭게발생한뇌경색에의한증상보다는이전에있던뇌경색의후유증으로생각된다. 그외 30명의환자에서는새롭게발생한신경학적증상은보이지않았으며, 임상적으로새롭게발생한뇌경색이의심되는소견은없었다. 이번연구는 36명 (39 개병변 ) 의비교적적은환자군을대상으로하였으며, 추적관찰기간이일정하지않으며, 영상검사를시행한대상이 13예로대상이적다는제한점이있었다. 또한적절한대조군이없으며, 대부분고위험군으로이루어진단일센터환자군으로구성되어이전의연구와직접적인비교에제한점이있었다. 결론적으로이전에보고된 non-tapered stent 와비교해 tapered stnet 의사용은시술에따른신경학적이상 (neurologic event), 즉조기결과에서이전에보고된연구와큰차이를보이지않았다. 하지만장기결과에서재협착을줄일수있을것으로생각되나아직장기결과에대한연구는부족한상황이며이에대해서다수의환자에서장기간의추적관찰을통한연구가필요할것으로사료된다. 참고문헌 1. Yadav J. Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE). Chicago: American Heart Association, Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, et al. Immediate and late clinical outcomes of carotid 370 대한영상의학회지 2011;65(4): submit.radiology.or.kr

7 정창우외 artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation 2001;103: Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001;357: Bosiers M, de Donato G, Deloose K, Verbist J, Peeters P, Castriota F, et al. Does free cell area influence the outcome in carotid artery stenting? Eur J Vasc Endovasc Surg 2007;33: ; discussion Hart JP, Peeters P, Verbist J, Deloose K, Bosiers M. Do device characteristics impact outcome in carotid artery stenting? J Vasc Surg 2006;44: ; discussion Skelly CL, Gallagher K, Fairman RM, Carpenter JP, Velazquez OC, Parmer SS, et al. Risk factors for restenosis after carotid artery angioplasty and stenting. J Vasc Surg 2006;44: Kirsch EC, Khangure MS, Morling P, York TJ, McAuliffe W. Oversizing of self-expanding stents: influence on the development of neointimal hyperplasia of the carotid artery in a canine model. AJNR Am J Neuroradiol 2002;23: Piamsomboon C, Roubin GS, Liu MW, Iyer SS, Mathur A, Dean LS, et al. Relationship between oversizing of self-expanding stents and late loss index in carotid stenting. Cathet Cardiovasc Diagn 1998;45: Yoon SM, Jo KW, Baik MW, Kim YW. Delayed carotid wallstent shortening resulting in restenosis following successful carotid artery angioplasty and stenting. J Korean Neurosurg Soc 2009;46: Brown KE, Usman A, Kibbe MR, Morasch MD, Matsumura JS, Pearce WH, et al. Carotid stenting using tapered and nontapered stents: associated neurological complications and restenosis rates. Ann Vasc Surg 2009;23: Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339: Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20: Rajagopal V, Rockson SG. Coronary restenosis: a review of mechanisms and management. Am J Med 2003;115: Schwartz RS, Henry TD. Pathophysiology of coronary artery restenosis. Rev Cardiovasc Med 2002;3 Suppl 5:S4-S9 15. Hoffmann R, Mintz GS. Coronary in-stent restenosis - predictors, treatment and prevention. Eur Heart J 2000;21: Schwartz RS, Huber KC, Murphy JG, Edwards WD, Camrud AR, Vlietstra RE, et al. Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model. J Am Coll Cardiol 1992;19: Hoffmann R, Mintz GS, Mehran R, Kent KM, Pichard AD, Satler LF, et al. Tissue proliferation within and surrounding Palmaz-Schatz stents is dependent on the aggressiveness of stent implantation technique. Am J Cardiol 1999;83: Sullivan TM, Ainsworth SD, Langan EM, Taylor S, Snyder B, Cull D, et al. Effect of endovascular stent strut geometry on vascular injury, myointimal hyperplasia, and restenosis. J Vasc Surg 2002;36: Wholey MH, Al-Mubarek N, Wholey MH. Updated review of the global carotid artery stent registry. Catheter Cardiovasc Interv 2003;60: Christiaans MH, Ernst JM, Suttorp MJ, van den Berg JC, Overtoom TT, Kelder JC, et al. Restenosis after carotid angioplasty and stenting: a follow-up study with duplex ultrasonography. Eur J Vasc Endovasc Surg 2003;26: Bosiers M, Peeters P, Deloose K, Verbist J, Sievert H, Sugita J, et al. Does carotid artery stenting work on the long run: 5-year results in high-volume centers (ELOCAS Registry). J Cardiovasc Surg (Torino) 2005;46: de Donato G, Setacci C, Deloose K, Peeters P, Cremonesi A, Bosiers M. Long-term results of carotid artery stenting. J Vasc Surg 2008;48: ; discussion Eskandari MK, Brown KE, Kibbe MR, Morasch MD, Matsumura JS, Pearce WH. Restenosis after carotid stent placement in patients with previous neck irradiation or endarterectomy. J Vasc Interv Radiol 2007;18: Gröschel K, Riecker A, Schulz JB, Ernemann U, Kastrup A. Systematic review of early recurrent stenosis after carotid submit.radiology.or.kr 대한영상의학회지 2011;65(4):

8 Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 angioplasty and stenting. Stroke 2005;36: Meyers PM, Higashida RT, Phatouros CC, Malek AM, Lempert TE, Dowd CF, et al. Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the cranio- cervical arteries. Neurosurgery 2000;47: ; discussion Hart R, Hindman B. Mechanisms of perioperative cerebral infarction. Stroke 1982;13: Tapered Stent 를사용한경동맥스텐트설치술에대한예비보고 1 정창우 1 김동현 1 안성환 2 김동욱 2 홍승정 1 김영숙 1 변주남 1 오재희 1 목적 : 본연구는내경동맥팽대부의협착을가진환자에서 tapered stent 를이용한치료결과를분석하고기존에보고된연구를통해 non-tapered stent 의치료성적과비교해보고자하였다. 대상과방법 : 2008 년 10월부터 2010 년 8월까지 tapered stent 를이용한 36명의환자에서 39개병변에대해분석하였다. 시술후환자의임상증상, 자기공명영상을통해합병증을평가하였다. 경동맥도플러초음파및혈관촬영술을포함하는전산화단층촬영을통해재협착에대한평가를하였으며, 임상적인무증상기간을평가하였다. 결과 : 모든 39예에서자가팽창성의 tapered stent 를총경동맥분지부에설치하였다. 총 3예에서뇌졸중이발생하였으며, 이중 1예에서는중증뇌졸중이발생하였다. 시술후확산강조자기공명영상에서 15예에서새로운병변이관찰되었으나 13예에서임상증상은없었다. 13예에서시행한추적검사에서모두재협착소견을보이지않았다. 임상적인추적관찰기간동안총 31명중 1명에서신경학적증상이새롭게발생하였다. 결론 : Tapered stent 를이용한경동맥협착의치료는안전하고효과적인치료법이며, 향후더많은환자를대상으로한추적검사가필요할것으로생각된다. 조선대학교의과대학 1 영상의학과학교실, 2 신경과학교실 372 대한영상의학회지 2011;65(4): submit.radiology.or.kr

서론 대상 대상및방법 방법 1821

서론 대상 대상및방법 방법 1821 Original Articles Korean Circulation J 1998;2811:1820-1827 두개외경동맥협착증에대한스텐트삽입술의추적결과 윤영섭 1 홍범기 1 최동훈 1 김선호 2 김동익 3 김승민 4 장양수 1 심원흠 1 Follow-up Results of Stent Placement for Extracranial Carotid Artery Stenosis