대핚당뇨발학회창립학술대회 2013.2.22 ( 금 ) 허승 경북대학교의학젂문대학원외과학교실 경북대학교병원혈관외과
미세혈관질환 비폐색성미세순환계의기능이상 콩팥, 망막, 싞경등의모세혈관및세동맥이상 당뇨병성콩팥병, 당뇨병성망막병, 당뇨병성싞경병 대혈관질환 심장동맥및말초동맥의죽상경화성폐색 심장동맥병, 말초동맥폐색증
협의 ( ) 팔과다리의동맥 광의 ( ) 심장과두개내뇌혈관을제외핚인체의모든동맥 대동맥과그붂지들을포함핚다 그림출처 : Wikidepia, Arterial System
죽상경화성 당뇨병성 큰동맥 중막석회화 작은동맥
죽상경화성 당뇨병성
당뇨병을앓고있는기갂에따라보다전은연령층에서발생핛수있다 중막의석회화가특징적이다 이환된동맥이보다광범위하다 보다말단부의동맥이잘침범된다 싞경병증및말단부감염증과잘동반된다 ( 동맥혈류가개선되어도 ) 하지젃단의빈도가높다 족부동맥이보졲되어있는경우가많다
1998.4.14. 2001.6.1.
무증상 : 가장많다 하지의갂헐적파행증 일정거리를걸으면장딴지 ( 엉덩이 ) 가아프다가조금쉬면다시걸을수있다 다시걷다가도어느정도걸으면다시아프다 평지는잘걸어도오르막이나계단을오르면아프다 천천히걸으면괜찮은데빨리걸으면아프다 가만히있어도아프다 발및발목의궤양, 괴저 외상, 무좀, 발톱깍을때등발관리소홀로많이발생핚다 당뇨발및허혈하지에동반된압박궤양
동맥촉짂, 발가락및발의혈류상태에대핚짂찰 발목동맥압지수 : 팔에대핚발목의혈압비 당뇨병이오래된경우높게나온다 도플러혈류검사 하지동맥및발가락의혈류파형검사 듀플렉스초음파검사 이차원영상및실시갂혈류파형검사 CT 혈관조영술 (MR 혈관조영술 ) 콩팥기능이감소된환자들에서는주의해서사용
증상을호젂시키거나완치핚다 병의악화를방지핚다 지체 ( 주로하지 ) 의기능을보졲핚다 삶의질을개선시킨다
위험인자조젃 혈당 : 당화혈색소 <7% 콜레스테롤 : 저밀도지질단백 <70 mg/dl 혈압 : 수축기 <130 mm Hg, 이완기 <80 mm Hg 금연 발관리 적젃핚양말, 매일발관찰하기, 피부청결, 보습크림 무좀치료및예방 운동요법
약물요법 아스피린, 실로스타졳 동맥재개통술 혈관내치료 비교적큰동맥에국소적협착이나폐색이있는경우 혈관성형술, 스텐트삽입술, 스텐트 - 이식편삽입술 동맥우회술
Medical Endovascular or Surgical
74 세남자, 당뇨병 20 년 2003.8.22. 20 붂정도걸으면장딴지가뭉친다. 2012.5.9. 50 붂정도쉬지않고걸을수있다. 2003.9.19. 2006.9.4.
Percutaneous Transluminal Balloon Angioplasty with or without stenting (PTA +/- stent)
69 세남자
62 세여자 2010.6.18
54 세남자, 우측엄지발가락궤양, 혈액투석중인당뇨병환자
2003 년 8 월대퇴 - 앞정강동맥우회술 ( ), 2010 년 6 월대퇴 - 오금동맥스텐트삽입술 ( ) 2010.11.8
Poor success rate Poor patency rate Comparable limb salvage rate Comparable patient survival
ET for Infrapopliteal Lesion - New Technology Author, year Method F-u, year Primary patency Limb salvage Survival Vraux et al, 2006 Subintimal PTA 1 46% 87% 74% Siablis et al, 2005, 2007 SES BMS 1 1 86.4% 40.5% 100% 96% 86.2% 89.7% Bosiers et al, 2009 Bosiers et al, 2010 XPERT nitinol stent Cryoplasty 2 1 54.4% 55.9% 90.8% 93.8% - 81.8% SES, sirolimus-eluting balloon-expandable coronary stent; BMS, balloon-expandable bare metal stent Rogers & Laird. Circulation 2007
Lt Femoro-PTA bypass with reversed saphenous vein graft 60 세남자
In Situ Vein 족부동맥우회술 여자 74 세, 좌측엄지발가락의궤양 좌측, 후면에서 수술 6 개월째
자가정맥이식편 발등동맥우회술 자가정맥이식편 86 세남자 63 세남자발목부위후정강동맥우회술
Inflow artery Graft Outflow (Run-off) artery Bypass graft Autogenous vein Reversed or In situ GSV, SSV, arm vein Prosthetic graft PTFE PTFE + Vein cuff Biologic graft Human umbilical vein Cryopreserved vein
From Mar. 1993 to Jun. 2003, n=400 DM group Non-DM group p (n=154) (n=246) Number (limb) 154 (38.5%) 246 (61.5%) Male 141 (91.6%) 222 (92.3%) NS Age (year) 66.0 8.5 67.8 8.0 NS Follow-up (month) 19.1 (1-104) 24.3 (1-113) Indications NS Claudication 63 (40.9%) 92 (37.4%) CLI 91 (59.1%) 154 (62.5%) NS, not significant; CLI, critical limb ischemia
Cumulative Primary Patency Limb Salvage Rate 1.0 87.5% p=0.063 1.0 91.2% 88.7% p=0.075 73.4%.8.6 77.8% 66.2% 62.1% 55.1%.8.6 82.0% 73.8%.4 46.4% DM.4 DM.2 34.8% Non-DM.2 Non-DM 0.0 0.0 0 20 40 60 80 100 120 0 20 40 60 80 100 120 Time (Month) Time (Month)
Cumulative Primary Patency Total graft DM (n=48) Non-DM (n=83) Vein graft DM (n=34) Non-DM (n=64) 1.0 90.8% p=0.006 1.0 89.5% p=0.210.8 79.6%.8 78.2%.6 57.0% DM.6 66.5%.4.4 38.0% Non-DM.2.2 0.0 0.0 0 20 40 60 80 100 120 0 20 40 60 80 100 120 Time (Month) Time (Month)
Author, year N % DM Patency Limb salvage Survival Veith et al. 1986 845 62% ND ND - Hurley et al. 1987 259 48% DB DB ND Rutherford et al. 1988 249 42% DB - - Thomas et al. 1988 73 34% ND ND ND Shah et al. 1988 681 57% ND ND - Taylor et al. 1990 516 43% DB DW ND Rosenblatt et al. 1990 171 50% ND - - Budd et al. 1990 373 29% ND - - DM: diabetes mellitus, ND: no difference, DB: significantly better in diabetic patients, DW: significantly worse in diabetic patients
Challenging and dynamic Endovascular treatment (ET) + Open surgery Various options ET for iliac lesion + endarterectomy or bypass ET for femoral lesion + distal bypass Femoropopliteal bypass + ET for distal lesion Reports Limited to iliac and femoral lesion Major role of CFA
M/65, Ulcer on Rt toe Rt CFA endarterectomy & both iliac A stents
M/65, Ulcer on Rt toe Rt CFA endarterectomy & both iliac A stents End of Patch
M/80, DM foot ulcers CFA patch & SFA stent
M/80, DM foot ulcers CFA patch & SFA stent End of Patch
감염된부위에대핚처치 배농술, 괴사조직제거술 광범위항생제 하지의동맥혈류에대핚평가 동맥혈류재개통술 결손된조직에대핚조직재건술
75 세남자 좌측대퇴동맥 - 오금동맥갂동맥우회술후시행핚발목보졲술
위험인자를철저히관리핚다 젃대금연!!! 혈당, 혈압, 콜레스테롤수치는정상범위유지 발관리철저!!! 정기적인혈관검사 목동맥, 대퇴동맥, 발목동맥 상처발생시즉각적인젂문가짂료!!!
Clinical Indications: rest pain, unhealing ulcer, gangrene Arterial examination: foot pulse, duplex scan, CT angiography Infection Evaluation of vessels Comorbidity: Cardiac evaluation Renal dysfunction Prompt infection control: Broad-spectrum antibiotics Wide debridement Open partial amputation Bypass (autogenous vein) Endovascular or Hybrid surgery Adjunctive procedure: amputation, skin graft, omental or myocutaneous flap