REVIEW ARTICLE J Surg Ultrasound 2015;2:16-21 JSU Journal of Surgical Ultrasound 복재정맥열절제술을위한초음파검사 계명대학교동산의료원외과 박의준 Duplex Ultrasound for Thermal Ablation of Saphenous Vein Ui Jun Park Department of Surgery, Dongsan Medical Center, Keimyung University, Daegu, Korea Received March 24, 2015 Revised April 24, 2015 Accepted April 27, 2015 Correspondence to: Ui Jun Park Department of Surgery, Dongsan Medical Center, Keimyung University School of Medicine, 56, Dalseong-ro, Jung-gu, Daegu 700-712, Korea Tel: +82-53-250-7315 Fax: +82-53-250-7322 E-mail: parkuijun@gmail.com Medical application of ultrasound has rapidly evolved and is becoming an essential tool in medical imaging. Ultrasound provides real time images and enables observation of anatomical changes as well as guidance in minimal invasive procedures. Duplex ultrasound is a well-established non-invasive tool used for varicose veins work-up. It has also been utilized for endovenous thermal ablation and follow-up after the procedure. The purpose of this article is to provide insightful information on performance of Duplex ultrasound during diagnosis and follow-up of varicose vein. The usefulness of Duplex ultrasound for endovenous thermal ablation is also discussed. Keywords: Varicose vein, Thermal ablation, Endovenous treatment, Saphenous vein, Duplex ultrasound 서론 하지정맥류의유병율은약 5-30% 로상당히높으며여성과남성의비율은약 3:1정도로여성에서유병율이높은것으로알려져있다.(1) 하지정맥류를포함한만성정맥질환은심부정맥이나표재정맥또는관통정맥등의판막기능이소실되어정맥압이증가하면서발생한다. 증가된정맥압은국소적으로또는하지전반에영향을미쳐정맥고혈압의증상을나타내게된다. 만성정맥질환은거미상혈관으로부터, 하지정맥류, 하지부종및통증을유발하며, 심하게는피부경화증및피부궤양을일으키게된다.(2) 하지정맥류진단에는여러가지침습적, 비침습적검사들이이용되고있다. 침습적검사들로는정맥조영법, 혈 관내초음파, 보행정맥압측정법등이있고, 비침습적검사들로는정맥초음파, 정맥혈량측증법, CT-정맥조영술및 MR-정맥조영술등이있다. 이들검사중정맥초음파는직접정맥역류를진단하면서역류가있는정맥의위치에대한정확한정보를얻을수있어정맥류의진단과함께치료계획을세울수있다. 하지정맥류의수술에서역류의원인이되는복재정맥은고전적으로고위결찰술및스트리핑을통하여제거하였다. 이러한수술을위해서는전신마취또는척추마취가필요하였으며, 입원이필요하였다. 그러나, 2000년대중반이후복재정맥의치료에열절제술의방법이도입된이후, 하지정맥류수술은국소마취로외래수술실에서도수술을진행할수있게되었다. 레이저나고주파를이용한 Journal of Surgical Ultrasound is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2015 by The Korean Surgical Ultrasound Society ISSN 2288-9140
Ui Jun Park: Duplex Ultrasound for Thermal Ablation of Saphenous Vein 복재정맥의열절제술은고전적인수술적치료에비해통증및합병증의발생이적은것으로보고되고있으며, 최근의하지정맥류치료의가이드라인은복재정맥의치료에레이저나고주파를이용한열절제술을우선적으로시행하도록권고하고있다.(3,4) 하지정맥류에서복재정맥열절제술을시행하기위해서는초음파는필수적인데, 진단에서부터수술중가이드및수술후복재정맥의폐쇄및합병증발생의추적관찰에이용된다. 본론 1. 수술전검사하지정맥류의성공적인치료를위해서는정확한수술전진단과함께초음파검사소견에따른수술전계획이필요하다. 하지정맥류의진단을위해서는 B모드, 컬러도플러및펄스도플러의트리플렉스초음파가표준적이다. B모드를통하여심부정맥, 표재정맥및관통정맥의위치, 모양, 직경및혈전의유무를관찰한다. 컬러도플러는정맥과동맥을쉽게구분하는데도움이되며, 혈전이있는경우색충만결손을보이고, 역류가있을경우색혈류의변화를관찰할수있다. 심부정맥의경우동맥과같이주행하기때문에동맥을확인하여슬관절하부의정맥을찾는데도움이될수있다. 컬러도플러의경우역류의시간을객관화할수없기때문에펄스도플러를이용하여정맥역류를확인하고역류의시간을계측하여야한다. 일반적으로 5-12 MHz 의선형프로브를사용하면서혜부이하의정맥을관찰하는데무리가없다. 하지정맥류를검사하기위해서는대복재정맥과소복재정맥의표재정맥을포함하여심부정맥및관통정맥을모두검사하여야한다. 검사는반듯이누운자세에서하지를외번시키고무릎을약간굽힌상태에서검사를시행하고, 슬와정맥및소복재정맥의경우엎드리거나일어선자세에서검사할수도있다. 환자의침대는 30-45 도정도역트렌델렌버그자세로검사를하여야하며, 이렇게하면정맥이충만되어잘묘출된다. 초음파검사는심부정맥부터시작하며횡단면으로 2-3 cm 간격으로프로브를이용하여압박과이완을반복하면서정맥의개통상태를평가하며, 종단면에서컬러도플러와펄스도플러를이용하여혈류의흐름을평가한다. 혈류 의흐름은자발적인흐름을평가하며, Valsalva 나프로브의원위부를압박 (augmentation) 하여역류의유무를평가한다. 심부정맥에대한검사후, 표재정맥과관통정맥에대한검사를시행한다. 표재정맥은대복재정맥의경우복재대퇴정맥접합부 (saphenofemoral junction, SFJ) 에서부터하방으로초음파검사를시행하며, 소복재정맥은복재슬와정맥접합부 (saphenopopliteal junction, SPJ) 에서시작하여하방으로검사를시행한다. 심부정맥에서와동일하게횡단면에서정맥의개통상태를평가하고, 직경을측정하며, 종단면에서혈류의흐름및역류의유무를검사한다. 하지정맥류수술을예정하고있다면, 수술을위해피부위에지워지지않는팬으로정확한부위를표시하여야한다. SFJ, SPJ 및관통정맥에서역류가관찰되는경우위치들을표시하여야한다. 정맥판막기능부전에따른역류의진단은펄스도플러로하게된다 (Fig. 1). 일반적으로 0.5초이상의역류가지속되는경우에정맥판막기능부전을진단하게되는데, 정맥의위치에따라진단기준에는차이가있을수있다. Labropoulos 등 (3) 은표재정맥과무릎하부의심부정맥의경우 0.5초, 관통정맥의경우 0.35초, 대퇴정맥및슬와정맥의경우 1초이상의역류가있을때정맥판막기능부전을진단할수있다고보고하였다. 역류현상은컬러도플러에서도측정을할수있으나역류정도가저평가되는경향이있어펄스도플러로진단을하는것이정확하다.(4) Fig. 1. Refluxing superficial vein. Reflux in GSV is seen following augmentation. The reflux time can be measured in the time-scale of spectral Doppler window. Continuous reflux is seen for 0.92 second in this case. 17
J Surg Ultrasound Vol. 2, No. 1, 2015 2. 복재정맥열절제술중초음파열절제술은레이저나고주파에서발생되는열로정맥내막의국소적인손상을일으켜혈전과섬유화를유도하여복제정맥을폐쇄하게된다. 대복재정맥에대한고주파열절제술후 2년째에정맥폐쇄율은약 85%, 재개통율은약 11%, 정맥내역류차단율은 90% 이며, 환자의만족도및증상개선정도는약 95% 로보고되고있다.(5) 레이저를이용한열절제술도성적은비슷하게보고되어열절제술후 2년째복재정맥폐쇄율은 93% 이다.(6) 복재정맥열절제술을안전하고효과적으로시행하기위해서는능숙한초음파기술과고해상도의초음파장비를이용하여정확하게초음파영상을확인할수있어야한다. 카테터를삽입하기위한복재정맥천자부터팽창액 (tumescent) 주입및카테터의위치확인의전과정에서초음파가사용된다. 주로왼손으로프로브를쥐고오른손으로천자및카테터작업을하여야한다. 1) 정맥천자및카테터위치복재정맥열절제술의시작은정맥을천자하는것으로시작된다. 정맥을천자하고가이드와이어를진입시키지못하면정맥이수축하여반복적인천자를하기어렵게된다. 이경우는보다근위부의정맥에다시천자를시도해볼수있다. 초음파유도하에정맥을천자하는방법은횡단면또는종단면모두에서시행할수있다. 횡단면에서천자하여와어어를삽입하고종단면에서와이어의위치를확인하는것이일반적인방법이다. 정맥이가는경우는 micro-puncture set를사용할수도있다. 정맥을천자하고와이어를삽입하면초음파로와이어가정맥내에위치한것을확인하고 sheath 를삽입한다. 이후와어어를제거하고열절제술에사용할카테터를복재정맥을따라삽입한다. 열절제술후발생되는혈전이심부정맥으로넘어가는것을최소화하기위해레이저나고주파카테터의끝은 SFJ 또는 SPJ 에서최소한 2 cm 거리를두고위치시킨다 (Fig. 2A). 2) 팽창액의주입및열절제술팽창액을주입하게되면복재정맥내의혈액이빠지면서정맥이위축되어초음파로정맥자체를관찰하는것이쉽지않기때문에팽창액을주입할때는카테터를삽입한상태에서주입하면정맥이위축되더라도고에코상 (echogenic) 의카테터를확인하면서팽창액을정맥주위에정확하게주입할수있다. 팽창액은생리식염수와국소마취제 Fig. 2. Location of catheter tip. (A) Optimal position of catheter tip is at least 2 cm away from saphenofemoral junction (SFJ). (B, C) Eye of tumescent fluid in cross-section, GSV is collapsed after tumescent injection. (D) Confirmation of the catheter tip after tumescent injection. 를혼합하여사용한다. 팽창액을주입하는것은 (1) 정맥을압박하여정맥내벽의열손상에방해가될수있는정맥내의혈액을비우고, (2) 정맥주위에있는신경및피부를멀리하여인접조직의열손상을막고, (3) 시술중통증을줄이는목적이있다. 초음파가이드하에팽창액을주입하면서카테터및정맥주위에둥근 halo 를형성하는지관찰한다.(Fig. 2B, C) 저자의경우프로브를종단면으로위치하여팽창액을주입할바늘과정맥의위치를확인하면서주입한다. 팽창액의주입을마치고나면, 초음파를이용하여정맥주위에충분히팽창액이주입되었는지확인한다. 그리고, 수술대는트렌델렌버그위치로바꾸고, 열절제술을시행하기전에다시한번 SFJ 나 SPJ 로부터카테터끝의위치를확인한다 (Fig. 2D). 초음파프로브를이용 18
Ui Jun Park: Duplex Ultrasound for Thermal Ablation of Saphenous Vein 하여카테터의끝을관찰하면서열절제술을시작하면, 열에의해끓어오르는모습을직접관찰할수있다. 열절제술을마치고나면마지막으로초음파를통하여심부정맥으로혈전이확장되었는지확인하여야한다. 3. 복재정맥열절제술후추적관찰복재정맥열절제술후추적관찰의목적은복재정맥의폐쇄및심부정맥혈전증의발생여부를평가하는데있다 (Fig. 3). 열절제술직후초음파검사에서심부정맥으로혈전이확장되는경우는드물지만, 추적관찰초기에심부정맥으로혈전이확장되는경우가있다 (Fig. 4). 복재정맥열절제술후발생하는혈전은일반적으로심부정맥에발생하는혈전증과는원인과자연경과에서차이를나타내기때문에 endovenous heat-induced thrombosis (EHIT) 으로따로분류한다. 복재정맥의열절제술후심부정맥으로혈전이확장되는경우는보고에따라차이가있지만, 대복재정맥의경우 0-8.0%, 소복재정맥의경우 0-5.7% 로보고된다.(6-13) EHIT의치료와추적관찰방법및기간에는논란은있으나, 복재정맥열절제술후초음파추적 관찰은필요할것으로여겨진다.(14,15) EHIT이발생한경우혈전의정도에따라치료가권고되고있어서, 심부정맥의 50% 이상을차지하거나심부정맥을막고있는경우에는심부정맥혈전증의치료에준하여항응고제치료하고, 50% 미만의경우에는초음파로추적관찰하도록권고되고있다.(14,16) 결론 하지정맥류의치료에있어서초음파진단은필수적이다. 복재정맥열절제술을위해서는초음파검사를통하여수술전역류의원인이되는정맥을정확히진단하여야한다. 또한, 열절제술을위해카테터를삽입하고, 정확한지점에카테터를위치시키고, 팽창액을주입하기위해수술중초음파가필요하다. 정확한초음파검사는복재정맥열절제술을안전하고효율적으로시행하고가능한합병증을발견하여치료하는데필수적이다. Fig. 3. Duplex Ultrasound performed one week after radiofrequency ablation. (A) Thrombosed great saphenous vein in B-mode cross section view, (B) Occluded great saphenous vein without thrombus extension to the common femoral vein. 19
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