대한내과학회지 : 제 84 권제 2 호 2013 http://dx.doi.org/10.3904/kjm.2013.84.2.274 혈관내초음파후퇴중발생한스텐트변형을성공적으로시술한 1예 계명대학교의과대학동산의료원심장내과 조현옥 조윤경 윤혁준 김형섭 남창욱 허승호 김권배 Stent Distortion Complicated by Intravascular Ultrasound Catheter Entrapment During Pullback Interrogation Hyun Ok Cho, Yun Kyeong Cho, Hyuck Jun Yoon, Hyungseop Kim, Chang Wook Nam, Seung Ho Hur, and Kwon ae Kim Division of Cardiology, Department of Internal Medicine, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea Entrapment of an intravascular ultrasound (IVUS) catheter during coronary intervention is rare, but can cause serious complications. Retrieval of an entrapped catheter can also lead to adverse results for implanted stents. We report a case in which the sheath tip at the guidewire exit port was entrapped and caused stent distortion during a post-stent IVUS procedure with automatic pullback. (Korean J Med 2013;84:274-278) Keywords: Intravascular ultrasound; Stent; Percutaneous coronary intervention 서론혈관내초음파를이용한경피적관상동맥중재술은치료전략수립뿐아니라스텐트혈전증및재협착의빈도를줄이는데효과적인것으로알려져있다 [1]. 혈관내초음파는그안정성이입증되어있지만가끔시술에따른부작용이보고된바있다. 이러한부작용은대개의경우혈관연축과 같은위험성이다소낮은것이지만극소수에서는혈관박리, 관상동맥의급성폐쇄등도보고되었다 [2,3]. 저자들은안정형협심증으로내원한환자에서좌전하행지에스텐트를삽입하고혈관내초음파를시행하는과정에서혈관내초음파카테터에의해발생한스텐트변형과이를다시혈관내초음파를이용하여진단하고치료하였던 1예를경험하였기에문헌고찰과함께보고하는바이다. Received: 2012. 3. 13 Revised: 2012. 4. 16 ccepted: 2012. 6. 8 Correspondence to Yun Kyeong Cho, M.D. Department of Internal Medicine, Dongsan Medical Center, Keimyung University College of Medicine, 96 Dalseong-ro, Jung-gu, Daegu 700-712, Korea Tel: +82-53-250-7998, Fax: +82-53-50-7034, E-mail: mk1997@dsmc.or.kr Copyright c 2013 The Korean ssociation of Internal Medicine This is an Open ccess article distributed under the terms of the Creative Commons ttribution - 274 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- Hyun Ok Cho, et al. Complication of intravascular ultrasound - 증례 74세여자가 1개월전부터발생한흉통을주소로본원에내원하였다. 환자는제2형당뇨병을진단받고투약중이었으며그밖에특이병력, 과거력및가족력은없었다. 심전도와심초음파에서는이상소견이없었으나심근관류단일광자방출전산화단층촬영 (single photon emission computed tomography, SPECT) 에서는좌전하행지영역에가역적인병변이있음을확인하였다. 이후시행한관상동맥조영술에서좌전하행지의근위부와중간부에서심한협착소견을확인할수있었다 (Fig. 1). 일차적으로풍선확장술을시행하였고 3.5 15 mm, 2.75 14 mm zotarolimus 방출스텐트 (Endeavor resolute, Medtronic, Minneapolis, US) 를좌전하행지의근위부와중간부에각각, 중복 (overlapping) 없이 12기압으로확장하여삽입하였다. 이후관상동맥조영술에서최적의결과를얻었으며 (Fig. 2) 삽입된스텐트를평가하기위해혈관내초음파 (intravascular ultrasound, IVUS) 를시행하였다. 혈관내초음파카테터 (tlantis SR Pro, oston Scientific Corporation, oston, US) 를좌전하행지의원위부에위치시킨후자동후퇴를하면서영상을얻었다. 그결과스텐트는관상동맥내에적절하게삽입되어있었고, 불완전확장 (underexpansion) 소견은관찰되지않았다 (Fig. 2, 2-1~2-3). 이후혈관내 초음파를수동으로당겨내던중카테터의끝부분 (tip of IVUS) 이근위부의스텐트위치에다다랐을때저항이느껴졌다. 저자들은일단가이딩카테터및유도철선, 초음파카테터를한꺼번에조심스럽게당겼으나결국초음파카테터는제거할수없었다. 그래서일단혈관내초음파카테터의유연성을높이기위해탐촉자 (transducer) 와그것을둘러싸고있는집 (sheath) 을분리하고탐촉자를먼저제거한뒤카테터집을당겼다. 이후제거된카테터집의끝 (sheath tip of guidewire exit port) 이찢어진걸확인할수있었으며 (Fig. 2C) 직후시행한조영술에서근위부스텐트부분에이전조영에서는보이지않던흐릿한영상 (haziness) 을관찰할수있었다 (Fig. 2D). 이를면밀히관찰하고자새로운가이딩카테터, 유도철선을적절히위치시킨뒤혈관내초음파를시행하였으며스텐트내스텐트현상 (stent in stent appearance; 스텐트의완전골절이후골절된스텐트의원위부가근위부로중첩되어들어가는현상, Fig. 2E-1), 스텐트골절 (stent fracture, Fig. 2E-2) 그리고불완전스텐트부착 (incomplete stent apposition, Fig. 2E-3) 의발생을확인할수있었다. 이를해결하기위해 3.5 mm 크기의풍선을이용해혈관확장술을시행한뒤 4.0 24 mm zotarolimus 방출스텐트 (Endeavor resolute, Medtronic, Minneapolis, US) 를이전삽입한근위부스텐트에중복하여좌주간지입구까지삽입하였다. 이후확 Figure 1. On pre-intervention angiography, () the left anterior oblique cranial view shows stenotic lesions in the proximal and middle left anterior descending artery, and () the right anterior oblique cranial view shows a significant stenotic lesion (arrows). - 275 -
- 대한내과학회지 : 제 84 권제 2 호통권제 630 호 2013 - C D E Figure 2. () Post-stent intravascular ultrasound (IVUS), right anterior oblique cranial view. () Longitudinal IVUS images of the proximal left anterior descending artery (LD) immediately following stent deployment. -1: Stent proximal edge; -2: Site of minimal stent area, 7.13 mm 2 ; -3: Stent distal edge. (C) Torn outer sheath tip of guidewire exit port during IVUS (arrow). (D) Post-IVUS retrieval angiogram with a dotted circle highlighting newly developed haziness. (E) Longitudinal IVUS images of the proximal LD after forceful removal of the IVUS catheter. E-1: Stent-in-stent appearance; E-2: Stent fracture; E-3: Iatrogenic incomplete stent apposition. 인한혈관내초음파에서는스텐트가혈관벽에잘부착되어있음을확인할수있었으며조영술에서도스텐트변형은더이상관찰할수없었다 (Fig. 3). 환자는다른합병증없이퇴원하였으며 9개월후추적관상동맥조영술및혈관내초음파에서스텐트가잘보존되어있음을확인할수있었다. 고찰혈관내초음파를이용한경피적관상동맥조영술은치료전략수립뿐아니라스텐트혈전증이나재협착의빈도를줄이는데효과적으로알려져있다 [1]. 혈관내초음파는그안 - 276 -
- 조현옥외 6 인. 혈관내초음파의합병증 - Figure 3. () final angiogram, right anterior oblique cranial view. () Longitudinal IVUS images of the proximal LD after additional stent implantation. -1: Previously shown stent-in-stent appearance -2: Previously shown stent fracture; -3: Previously shown incomplete stent apposition. 정성이입증되어있지만가끔시술에따른부작용이보고되었으며이러한부작용은대개의경우혈관의연축처럼위험성이다소낮은것이지만극소수에서는혈관의박리, 관상동맥의급성폐쇄등도보고되었다 [2,3]. 미국심장학회 (merican Heart ssociation) 에서 2,207명의환자를대상으로시행한다기관공동연구에의하면, 혈관내초음파의가장흔한합병증은관상동맥연축 (2.9%) 이었으며이외합병증 (0.4%) 으로는관상동맥의급성폐쇄, 색전증, 혈관박리및혈전등이있다. 그리고기술적인실패에의한합병증 (0.4%) 도보고되었는데유도철선의꼬임및카테터망가짐등이그것이다 [2]. 유럽의다기관연구에서도전체합병증의빈도를 1.1% 로보고하였으며일시적인관상동맥연축 (0.55%), 박리 (0.28%) 그리고유도철선꼬임 (0.28%) 등이었다. 기술적인실패로인한합병증의발생도보고되었는데한연구자는혈관내초음파사용중끊어진카테터를색전방지장치 (distal embolic protection device) 를이용해안전하게관상동맥밖으로제거한증례를보고하였다 [4]. 그리고다른연구자들도비슷한증례를보고하였으며이러한카테터포착 (catheter entrapment) 의원인으로스텐트의혈관내부착이나빴을가능성 (malapposed stent strut) 및유도철선의위치가잘못되었을경우 (loss of wire position), 그리고반복사용으로인한카테터의변형들을설명하고있다 [5]. 본증례에서는혈관내초음파의자동후퇴과정을마치고나서혈관내초음파를수동으로혈관밖으로당겨내는 과정에서카테터집의끝 (sheath tip of guidewire exit port) 이근위부스텐트에걸렸고이를제거하는과정에서스텐트가변형되었다. 이과정이일어난후우리는다시혈관내초음파를시행하였으며첫번째혈관내초음파를당겨낸후조영술에서보였던흐릿한영상 (haziness) 의원인을알수있었으며또하나의스텐트를망가진스텐트에겹쳐삽입하여문제를해결할수있었다. 카테터집의끝에의해발생되는스텐트포착은간간이발생하는것으로알려져있으며흉통, 혈류의장애등의문제가발생하지않는다면면밀한관찰을하며지켜볼수도있다. 하지만이것이흉통의발생, 원위부혈류의장애, ST 분절변화등의임상적문제를야기한다면올가미 (snare) 를이용해빼내는방법, 다른스텐트를삽입하거나수술적제거를고려하여야한다. 만약스텐트삽입후혈관내초음파를시행후혈관밖으로당겨내는과정에서저항이느껴질때, 일단혈관내초음파를원위부로다시위치시킨후다른유도철선을위치시키고이를통해스텐트가삽입된부위에다시한번풍선확장술을시행한다면삽입되어있던스텐트의모양에변화를줄수있어혈관내초음파를제거하는데용이할것으로생각되며스텐트의변형을최소한으로예방하는한방법으로사용될수있겠다. 요약관상동맥중재술을하는과정에서의혈관내초음파의역 - 277 -
- The Korean Journal of Medicine: Vol. 84, No. 2, 2013 - 할이중요해지면서그이용빈도또한높아졌고따라서이의사용에따른합병증도간간이보고되고있다. 저자들은스텐트를좌전하행지에삽입한이후그부착정도를파악하고자혈관내초음파를시행하였고이를혈관으로부터제거하는과정에서발생한스텐트의변형을새로운혈관내초음파를통하여확인하고여기에또하나의스텐트를추가삽입함으로써좋은결과를얻었기에이를보고하는바이다. 중심단어 : 혈관내초음파 ; 스텐트 ; 관상동맥중재술 REFERENCES 1. Roy P, Steinberg DH, Sushinsky SJ, et al. The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents. Eur Heart J 2008;29:1851-1857. 2. Hausmann D, Erbel R, libelli-chemarin MJ, et al. The safety of intracoronary ultrasound: a multicenter survey of 2207 examinations. Circulation 1995;91:623-630. 3. atkoff W, Linker DT. Safety of intracoronary ultrasound: data from a Multicenter European Registry. Cathet Cardiovasc Diagn 1996;38:238-241. 4. Chang CP, Lin JJ, Hung JS, Pai PY, Hsu CH. Retrieval of dislodged coronary intravascular ultrasound catheter with embolic protection device. Int Heart J 2009;50:121-125. 5. Sasseen M, urke J, Shah R, et al. Intravascular ultrasound catheter entrapment after coronary artery stenting. Catheter Cardiovasc Interv 2002;57:229-233. - 278 -