02-06 구관우

eissn 2287-1683 pissn 1738-8767 Journal of Trauma and Injury Vol. 28, No. 4, December, 2015 Original Article 둔상에의한흉부대동맥손상에서 TEVAR 에관한임상연구 을지대학교병원흉부외과, 1 외과, 2 부산대학교병원외상외과 구관우, 최진호, 최민석, 박상순, 설영훈 1, 고승제 1, 예진봉 1, 김중석 1, 김영철 1, 황정주 2 - Abstract - Clinical Analysis of TEVAR in Blunt Thoracic Aortic Injury Gwan Woo Ku, M.D., Jin Ho Choi, M.D, Min Suk Choi, M.D., Sang Soon Park, M.D., Young Hoon Sul, M.D., Ph.D. 1, Seung Je Go, M.D. 1, Jin Bong Ye, M.D. 1, Joong Suck Kim, M.D. 1, Yeong Cheol Kim, M.D. 1, Jung Joo Hwang, M.D. 2 Department of Thoracic and Cardiovascular Surgery, 1 Department of Surgery, Eulji University Hospital, Daejeon, Korea 2 Department of Trauma Surgery, Pusan National University Hospital Trauma Center, Busan, Korea Purpose: Thoracic aortic injury is a life-threatening injury that has been traditionally treated by using surgical management. Recently, thoracic endovascular aortic repair (TEVAR) has been conducted pervasively as a better alternative treatment method. Therefore, this study will focus on analyzing the outcome of TEVAR in patients suffering from a blunt thoracic aortic injury. Methods: Of the blunt thoracic aortic injury patients admitted to Eulji University Hospital, this research focused on the 11 patients who had received TEVAR during the period from January 2008 to April 2014. Results: Seven of the 11 patients were male. At the time of admission, the mean systolic pressure was 105.64±24.60 mm Hg, and the mean heart rate was 103.64±20.02 per minute. The median interval from arrival to repair was 7 (4, 47) hours. The mean stay in the ICU was 21.82±16.37 hours. In three patients, a chimney graft technique was also performed to save the left subclavian artery. In one patient, a debranching of the aortic arch vessels was performed. In two patients, the left subclavian artery was totally covered. In one patient whose proximal aortic neck length was insufficient, the landing zone was extended by using a prophylactic left subclavian artery to left common carotid artery bypass before TEVAR. There were no operative mortalities, but a patient who was covered of left subclavian artery died from ischemic brain injury. Complications such as migration, endovascular leakage, collapse, infection and thrombus did not occur. Conclusion: Our short-term outcomes of TEVAR for blunt thoracic aorta injury was feasible. Left subclavian artery may be sacrificed if the proximal landing zone is short, but several methods to continue the perfusion should be considered. [ J Trauma Inj 2015; 28: 232-240 ] Key Words: Blunt thoracic aortic injury, TEVAR Address for Correspondence : Jin Ho Choi, M.D. Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, 95, Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel : 82-42-611-3195, Fax : 82-42-259-1111, E-mail : jinhc@eulji.ac.kr Submitted : November 9, 2014 Revised : November 14, 2015 Accepted : December 9, 2015 232

Gwan Woo Ku, et al.: Clinical Analysis of TEVAR in Blunt Thoracic Aortic Injury I. 서론 근성 (accessibility) 등을종합적으로고려하여판단하였다. 외상으로인한뇌손상과흉부대동맥손상은외상으로인한사망률의대부분을차지한다.(1,2) 또한관통상또는둔상으로인한흉부대동맥손상이발생하였을경우현장에서의사망률은각각 80% 에서 90% 가까이이르고있으며,(3,4) 초기생존후에도치료를받지않았을경우 24시간이내에 32%, 2주이내에 74% 가사망한다.(5) 따라서즉각적인진단과치료가필수적이다. 최근에는수축기혈압을 120 mmhg 이하로유지하거나평균동맥압을 80 mmhg 이하로유지하면대동맥파열의위험성을의미있게줄일수있는것으로보고하고있고,(6) 맥박수와혈압을조절함으로써동반된다른부위의손상을치료하거나안정시킬수있을때까지흉부대동맥의수술적치료를늦출수있는것으로보고하고있다.(6-8) 전통적으로흉부대동맥손상의치료는수술적치료가주치료이다. 수술시좌측개흉술, 좌측폐허탈, 대동맥겸자를하는동안심폐우회로술을이용하여원위부관류를유지해야한다. 그러나뇌출혈, 복강내출혈, 폐손상이동반되었을경우수술진행에어려움이따른다. 수술적치료가불가능하거나여러합병증이우려되는고위험도환자에서흉부혈관내대동맥치료 (thoracic endovascular aortic repair, TEVAR) 를시행할수있다. 흉부혈관내대동맥치료는 1991년에시작되어빠르게확산되고있으며, 수술적방법보다비침습적이고시술시간이짧으며뇌출혈, 복강내출혈및골반골절등이동반된환자에서많이시행되고있다. 2011년에혈관외과협회 (Society for Vascular Surgery) 의진료지침에따르면 TEVAR는선택적환자에서TEVAR 치료를권고하고있다.(10) 본연구에서는흉부둔상에의한흉부대동맥손상의환자에서 TEVAR시술의치료성적을분석하고, TEVAR의흉부대동맥손상에대한효용성을알아보고자하였다. II. 대상및방법 1. 대상 2008년 1월부터 2014년 4월까지대전을지대학교병원에서흉부둔상으로인한흉부대동맥손상을진단받은환자중 TEVAR를시행한환자를대상으로하였다. 같은기간내에흉부대동맥손상을진단받은환자가총 21명있었으며, 그중 11명에게 TEVAR를시행하였다. 수술적치료를할것인지, TEVAR를할것인지, TEVAR를한다면 hybrid procedure 혹은 chimney technique을더불어할것인지에대한판단은대동맥손상의위치, 근위부안착지점 (landing zone) 의길이, 활력징후, 환자의나이, 기구의접 2. 방법대동맥손상부위의근위부와원위부의내경이최소한 20 mm 이상의환자에서시행하였으며, 총대퇴동맥 (Common femoral artery) 의내경이 8 mm 이상의환자에서시행하였다. 그라프트크기의선택은수술전시행한 CT와수술중에시행한조영술에서대동맥굵기를측정한후직경이 20% 더큰것을선택하였다. 환자는앙와위에서국소마취를한후우측총대퇴동맥을수술적으로노출후스텐트의외장 (sheath) 을삽입하고스텐트그라프트를통과시켰다. 대동맥조영술하에서그라프트의정확한위치를확인하고안착을시킨후그라프트주위누출 (endovascular leakage) 이없는것을확인한후수술을마쳤다. 스텐트그라프트는 S&G Biotech (S&G Biotech, Seoul, Korea), VALIANT (Medtronic Vascular : Sunrise, Fla) 사용하였다 (Table 1). 다양한크기와형태를가지고있는 VALIANT (Medtronic Vascular : Sunrise, Fla) 를대동맥궁과의적합성이우수하기때문에 2011년부터모든환자에게사용하였다. 마취방법은 TEVAR 및 chimney techqniue과같이 endovascular procedure만시행한경우에는모두국소마취하에서시행하였고, 좌측경동맥-쇄골하동맥우회로술및대동맥궁분지혈관우회로술 (debranching) 을동시에시행한환자 2 명에게만전신마취하에서시행하였다 (Table 1). 헤파린은다른장기의출혈위험이높았던 5명에게서는사용하지않았다. 6명에게헤파린을사용하였으며그용량은 Table 1에정리하였다. TEVAR 시술전시행한흉부컴퓨터단층촬영에서좌우척추동맥의크기를비교하여좌측척추동맥의크기가같거나굵을경우최대한좌측쇄골하동맥을보존하려고하였다. 스텐트그라프트가대동맥궁의목표지점에안착시키기위해좌측쇄골하동맥또는좌측총경동맥부위까지스텐트의안착지점 (landing zone) 이차지할수있다. 이럴경우신경학적인합병증과허혈의위험성을최소화하기위하여대동맥궁가지의혈류의순행을유지하려고하였다. 즉좌측척추동맥의굵기가우측보다더굵으며스텐트그라프트의안착지점이좌측쇄골하동맥을막을경우좌측쇄골하동맥의혈류를유지하기위해좌측총경동맥과좌측쇄골하동맥우회로술과 chimney technique을사용하였다. chimney technique은 Greenberg 등에의해최초로기술되었는데 EVAR 시행중에스텐트그라프트에의해막혀진신동맥의혈류보전을위해고안되었다.(38) Chimney technique은상완동맥을통해서시행하였으며흉부대동맥스텐트그라프트를시술후 chimney graft (Sinus (OptiMed, Germany), Precise (Cordis, USA), Astron (BIOTRON- 233

- Journal of Trauma and Injury Vol. 28, No. 4 - IK, Germany)) 를유도철사 (Guide wire) 를이용하여좌측쇄골하동맥에삽입후좌측쇄골하동맥기시부밖의대동맥안쪽으로 2~3 cm 정도진입을시킨후전개하였다. 그러나 chimney technique은그라프트의막힐위험성과그라프트주위유출의위험성이있으므로주의깊은추적관찰이필요하다. 따라서좌측총경동맥과좌측쇄골하동맥우회로술을할수없을만큼시간이촉박한상황에서 chimney technique을사용하였다. 그러나 1명의환자에서대동맥의손상부위는대동맥협부였으나파열이근위부에서우측무명동맥부위까지진행하여스텐트그라프트의안착점이우측무명동맥을막을수있어 12 mm INTERGARD Straight (InterVascular S.A. (MAQUET Cardiovascular), La Ciotat, France) 를이용하여상행대동맥에서무명동맥에연결하고, 좌측총경동맥을 8 mm INTERGARD Straight를이용하여좌측쇄골하동맥을무명동맥에연결하였고, 좌측쇄골하동맥은쇄골의상부에서좌측총경동맥에좌측쇄골하동맥을연결하였다. 모든대동맥궁의가지는결찰후절단 (Debranching) 하였다. 대동맥궁의가지의혈류의흐름을확인한후 TEVAR를시행하였다. 저자에서 11명의환자중 5명의환자에서위에서언급한추가적인수술이필요하였다. 비록하행흉부대동맥에 TEVAR를시행하였지만하행흉부대동맥류혹은 B형대동맥박리에대하여 TEVAR를할때처럼, 척수혈류공급에특히중요하다고알려진, 낮은높이에위치한늑간동맥까지덮을정도로스텐트그라프트가길지는않았다 (Table 1). 그래서수술전후로혈압이낮지않게최대한유지하는것외에는특별히뇌척수액배액등과같은특별한조치는취하지않았다. 3. 추적관찰환자의정보는전자의무기록에서확인하였다. 추가로필 요한정보가있을경우환자또는가족과전화인터뷰를하였다. 연락이되지않는환자들에대해서는국민건강보험공단의보험자격의상실여부를확인하여간접적으로사망여부를확인하였다. 이를통하여모든환자들에대하여추적관찰이가능하였으며, 평균추적관찰기간은 24.55±24.51 개월이었다. 4. IRB 이연구는을지대학교생명윤리심의위원회의승인을받고실행하였다. 5. 통계기법 IBM SPSS Statistics (version 19, SPSS Inc., Chicago, IL) 를사용하였다. 데이터는평균 ± 표준편차, 중앙값 (25 percentile, 75 percentile) 혹은비율 (%) 로표기하였다. 만약데이터가정규분포를하고있다면평균 ± 표준편차를계산하였고, 정규분포를하고있지않다면중앙값 (25 percentile, 75 percentile) 으로표기하였다. III. 결과 11명의환자중 7명 (63.6%) 이남자였으며, 환자의평균나이는 51.45±13.73세 (26~77) 이었다. 둔상에의한흉부대동맥손상의원인중교통사고가가장많았으며이중보행자사고가 6명 (54.5%), 운전자사고가 2명 (18.2%), 승객사고가 1명 (9%), 오토바이운전자사고가 1명 (9%) 이었고, 1명 (9%) 의환자에서낙상이있었다 (Table 2). 평균손상심각도점수 (Injury severity score, ISS) 는 29.18±4.26 (21~34) 이며, 동반손상부위는뇌출혈이 3명 (27.3%), 복강내장기 Table 1. Procedural Information of TEVAR. Patient Stent size* Manufacturing company Additional procedure Anesthesia Dosage of heparin (IU) Patent LSA** 01 34 34 120 S&G Biotech Chimney technique Local 0 Yes 02 34 34 150 Medtronic Local 0 Yes 03 34 34 100 Medtronic Local 300 Yes 04 26 26 130 S&G Biotech Subclavian coverage General 0 No 05 42 42 200 Medtronic Debranching General 0 Yes 06 36 32 130 S&G Biotech Carotid-subclavian bypass Local 3000 Yes 07 36 36 150 Medtronic Subclavian coverage Local 5000 No 08 38 38 100 Medtronic Local 0 Yes 09 30 30 100 Medtronic Chimney technique Local 3000 Yes 10 30 30 150 Medtronic Chimney technique Local 0 Yes 11 34 34 130 S&G Biotech Local 3000 Yes * stent size=proximal diameter distal diameter length (mm) ** LSA=left subclavian artery 234

Gwan Woo Ku, et al.: Clinical Analysis of TEVAR in Blunt Thoracic Aortic Injury 손상이 6명 (54.5%), 척추골절이 6명 (54.5%), 골반뼈골절이 3명 (27.3%), 사지의골절이 7명 (63.6%) 이었다. 내원당시평균수축기혈압은 105.64±24.60 mmhg였으며, 평균심박동수는 103.64±20.02회 / 분이었으며, 응급실내원후치료까지의시간의중앙값은 7 (4, 47) 시간이었다 (Table 2). 평균중환자실재원기간은 21.82±16.37 (3~48) 이었다. 모든환자에서대동맥의손상은대동맥협부에서발생하였다. TEVAR를시행한 11명모두컴퓨터단층촬영소견상가성동맥류로진단되었다. 총 9명 (81.82%) 의환자에서대동맥이외의동반손상에대하여추가적인수술이필요하였으며, 그중 8명의환자에서 TEVAR시술후추가적인수술을시행하였다. TEVAR를시행한 11명의환자중 4명 (36%) 의환자에서는좌측쇄골하동맥직하방에안착지점을확보하였다. 4명 (36%) 에서는안착지점의길이가짧아서 TEVAR를하면서좌측쇄골하동맥입구를덮어야해서, 그중 3명 (27%) 에게는 Chimney technique을이용하여좌측쇄골하동맥혈의흐름을보존하였고, 1명 (9%) 에서좌측경동맥-쇄골하동맥우회로술 (carotid-subclavian bypass) 을이용하여좌측쇄골하동맥혈의흐름을보존하였다. 1명 (9%) 은대동맥의손상이좌측쇄골하동맥입구바로맞은편에위치하고, 그로부터무명동맥입구까지의길이가 2 cm 밖에되지않아서 8 mm, 12 mm INTERGARD Straight Graft를이용하여상행대동맥으로부터무명동맥, 좌측경동맥및좌측쇄골하동맥으로의우회로를만든후대동맥궁분지혈관들의입구를결찰하였다 (Debranching). 나머지 2명 (18%) 에게는추가적인시술및수술없이좌측쇄골하동맥을덮었다 (Subclavian coverage) (Table 1). TEVAR 시술한환자중 좌측쇄골하동맥을덮은 2례중 1례에서시술후 5일에뇌혈관경색으로사망하였고, 나머지 1례에서는그라프트주위유출 (endoleak) 이지속되어 Amplatzer (Boston Scientific, Miami,Fla) vascular plug 14 mm를이용하여추가적으로좌측쇄골하동맥혈관내색전술을시행하였다. 시술후사망한 1명을제외한환자들은현재평균 24.55± 24.51개월동안추적관찰중이며사망한환자는없으며, 아직그라프트와관련된합병증즉, 그라프트의이동, 주위유출, 찌그러짐, 감염, 혈전등의초기합병증및그라프트의골절, 대동맥천공, 가성대동맥류등의합병증은발생하지않았지만장기적인추적관찰이필요하다. 2명의환자에서일상생활이불가능한데경추손상으로사지마비가발생한 1명의환자와뇌출혈로인한후유장애로 1명의환자에서현재까지재활치료중이다. IV. 고찰흉부둔상에의한흉부대동맥손상은높은사망률을보이는중증응급질환이며, 외상으로인한사망률중뇌손상다음으로가장흔한원인이다.(11) 흉부둔상에의한흉부대동맥손상의대동맥손상외의동반손상은 69% 에서 98.3% 까지보고되고있다.(12,13) 본연구에서도모든환자에서동반손상이있었다. 흉부대동맥손상의기전은충격으로인하여발생하는감속이나대동맥의틀어짐으로흉골과흉추사이에대동맥이눌리면서발생하며, 이때동반한복압의상승으로인한수격 (water-hammer) 효과로흉부대동맥의압력이올라가서파열되는것으로알려져있다.(2,9) 둔상으로인 Table 2. Patients demography. Patient Sex Age (years) ISS (Injury Severity score) Interval from diagnosis to Repair (h) Mechanisms of Trauma Follow Up (months) 01 F 43 29 003 Pedestrian 33 02 M 55 34 006 TA(driver) 14 03 F 77 24 072 Pedestrian 58 04 F 52 29 004 Pedestrian 00 05 M 42 29 008 Motocycle(driver) 01 06 M 60 34 007 TA(driver) 30 07 M 62 34 023 Pedestrian 03 08 M 58 32 192 Fall 01 09 M 26 21 006 Passenger 24 10 F 53 29 002 Pedestrian 32 11 M 38 26 047 Pedestrian 74 Sex: M:F=7:4 Age (years): 51.45±13.73 ISS: 29.18±4.26 Interval from diagnosis to Repair (h): 33.64±57.06 (median 7) Follow Up (months): 24.55±24.51 235

- Journal of Trauma and Injury Vol. 28, No. 4 - 한흉부대동맥의손상은 80% 이상에서대동맥협부와동맥관인대의 20 mm 이내에서발생한다.(2,9) 이는본연구에서도같은양상을보였다. 흉부대동맥손상이대동맥협부에서가장많이발생되는이유는대동맥협부의구조적특성에기인한다. 대동맥협부에존재하는동맥관인대는대동맥과폐동맥에연결된구조물로서, 이부위는다른대동맥부위와달리상대적으로고정되어있으므로급속한감속시대동맥협부이외의부위가관성에의해이동되어대동맥협부의손상이발생하게되며이기전으로대동맥손상이발생한다.(14) 흉부대동맥손상의분류로서병리학적진단으로내막, 중막, 외막의손상에따라구분하였는데임상적으로적용하기에는제한이따른다.(9) 컴퓨터단층촬영소견으로대동맥손상의정도를구분할수있는데, 1등급은내막파열 (intimal tear), 2등급은중막내혈종 (intramural hematoma), 3등급은가성동맥류 (pseudoaneurysm), 4등급은대동맥파열 (rupture) 이다 (15). 대부분사고현장에서흉부대동맥손상으로사망하는경우는대동맥파열에기인하다. 대동맥손상에의한가성대동맥류는시간이지남에따라대동맥류가커지고대동맥이파열될가능성이높아지므로대동맥파열의가능성이높은환자에게는적극적인치료가요한다. 내막판 (intimal flap) 이 10 mm 미만이면서대동맥주위혈종이없거나소량인대동맥손상인경우혈압조절과같은비수술적치료를하면서추적관찰을한다. 이런대동맥손상은전체대동맥손상의 10% 을차지한다.(16) 본연구에서 TEVAR를시행한 11명모두컴퓨터단층촬영소견상가성동맥류로진단되었지만, 본연구에는포함되지않았지만본원에서외상성대동맥손상으로진단받은환자중에서대동 맥박리에서와같은가성내강이상행대동맥에국한된 1명이있었으나비가역적뇌손상으로치료를하지않았고, 10 mm 이내의작은내막파열만있어서 TEVAR 및수술적치료를시행하지않고지켜본 2명도있었다. 흉부대동맥손상환자중 7% 의환자에서는단순흉부촬영에서특이한이상소견을보이지않는다.(17) 따라서흉부둔상에의한흉부대동맥손상이의심되는환자에서는확진을위하여흉부컴퓨터단층촬영과대동맥조영술이필요하다. 1990년이후에는나선식컴퓨터단층촬영이보급되면서컴퓨터단층촬영만으로도정확하게대동맥손상을진단할수있게되었다.(7,18) 그러나나선식컴퓨터단층촬영으로진단이불명확할경우, 대동맥조영술이나경식도심초음파, 혈관내초음파, 자기공명영상이도움이될수있다.(17) 경식도심초음파의경우환자의비정상적인심근운동이나심낭삼출및판막에대해서도추가적으로확인할수있다.(17) 본연구에서도모든환자에서컴퓨터단층촬영으로확진할수있었다. 흉부대동맥손상환자의 90% 의환자들이수상후 24시간이내에사망하기때문에과거의흉부대동맥손상에대한치료는진단즉시개흉술하대동맥치환술을시행하였다.(9) 그러나최근에는동반손상이있거나대동맥손상의정도가심하지않으면수술을지연할수있다.(18-20) 흉부대동맥손상이있는환자중생존하여병원에내원한환자중대동맥에대한응급수술을요하는대동맥손상이아니나, 생체징후가불안정한환자에게는대동맥이외에간, 비장과같은복부의고형장기의손상가능성이높으므로개복술을먼저시행하기를권고하는보고도있다.(21) 흉부대동맥손상시 A B Fig. 1. TEVAR with Subclavian carotid bypass for a patient with traumatic aortic injury: (A) Postoperative computed tomography scanning shows TEVAR and Lt. subclavian artery bypass to Lt. common carotid artery (3-demensional reconstructions). (B) Complete schematic view of subclavian carotid bypass. 236

Gwan Woo Ku, et al.: Clinical Analysis of TEVAR in Blunt Thoracic Aortic Injury 간을기준으로손상 16시간전과 16시간이후에수술적치료를시행한군을비교연구한결과에따르면 16시간이전에수술한군이사망률이더높았고, 하지마비가더많았다.(19) 이는병원내원후정확한환자평가와동반손상에의한추가적인전신손상을최소화한후수술하는것이환자의예후에긍정적인영향을줄것으로사료된다. Demetriades 등의보고에따르면, 대동맥손상환자에대한 TEVAR 또한, 위와같은경향을보였다.(22) 이연구에따르면, 사고후 24시간을기준으로손상후 24시간이전 TEVAR를시행한환자들에서손상후 24시간이후 TEVAR 를시행한환자보다더높은사망률을보였다. 이는심각한동반손상이없는환자들에대해서만비교했을경우에도마찬가지였다.(22) 본연구에서는응급실도착후시술시작까지걸린시간의중앙값이 7시간이었다. 비록사고후부터의시간은확인하기힘들었지만외부병원에서전원온환자없이모두사고직후바로본원으로이송된환자들이라는점을고려할때본연구에서시행한 TEVAR 또한사고후 24시간이내에했다고볼수있다. 본연구에서는환자수가많지않고, 특히조기사망률이거의없어서위의논문들에서와같이비교연구를할수는없었지만, 저자들은현재상기연구결과를고려하여, 너무서두르지않고활력징후를안정적으로만든후 TEVAR를시행하려한다. 저자들의경험에서활력징후가불안정한경우대동맥손상보다는다른장기손상에의한경우가더많았다. 본연구에서의 11명의활력징후는내원당시평균수축기혈압 105.64±24.60 mmhg, 평균심박동수는 103.64±20.02회 / 분으로심각하게불안정하지는않았다. 하지만이는 TEVAR를시행한환자들만을 후향적으로조사한것이고, 전체외상성대동맥손상환자중에서다른장기의불가역적인손상이심하거나활력징후가불안정해서 TEVAR를굳이시행하지않은환자가 2명있었다. 혈관외과협회의지침에서도, 다른심각한동반손상이없다면 24시간이내에대동맥을치료하되, 다른손상이있다면이를먼저치료후입원기간중에대동맥을치료하라고권하고있다.(10) 흉부대동맥손상환자에서의개흉술을이용한수술은좌측개흉술, 좌측폐허탈, 대동맥겸자를하는동안심폐우회로술을이용하여원위부관류를유지해야한다. 수술후높은조기사망률및하지마비의발병률로점차적으로대동맥겸자를하는동안복부와하지의관류를유지하는원위부관류를하였고그후좌측심장우회로술혹은심폐우회로술로관류를하면서하지마비발생률이감소하고사망률또한낮아졌다.(23-26) 최근엔수술시원위부우회로술과헤파린의최소한사용, 엄격한혈압조절과환자의상태를안정하게만든후수술을진행함으로하지마비는 2% 까지줄어들었으나사망률은 12~26% 로높다. 흉부혈관내치료는 1997년부터대동맥둔상에대한 TEVAR가보고되었으며,(27) 국내에는 2008년대동맥손상에대한 TEVAR가처음보고되었다.(23) TEVAR는단기성적에있어서낮은조기사망률과하지마비발생률을보였다.(15) 특히수술적치료와비교를하면조기사망률은유의하게낮았으며, 하지마비발생률은비슷하거나더낮은결과를보였으며,(10,28-29) 또한 TEVAR는수술로인한호흡기합병증을줄일수있으며수술과비교해비침습적인접근으로출혈양도줄일수있는장점이있다. 그러나 A B C Fig. 2. TEVAR using the chimney technique for a patient with traumatic aortic injury: (A) & (B) Postprocedural computed tomography scanning shows TEVAR with chimney technique in Lt. subclavian artery. (C) Complete schematic view of TEVAR using the chimney technique. 237

- Journal of Trauma and Injury Vol. 28, No. 4 - TEVAR 시술의제한점은상용화할수있는스텐트그라프트의굵기에제한이있으므로대동맥궁의굵기와스텐트그라프트의안착을위해 15 mm 이상의공간이확보되어야함으로손상부위에서좌측쇄골하동맥사이의간격이 15 mm 이상이어야시술이용이하다. 또한스텐트그라프트의통과를위해대퇴동맥과장골동맥의내경이 8 mm 이상이어야한다. 스텐트그라프트시술후좌측쇄골하동맥이스텐트그라프트에의해막혀좌측상지의허혈, 척추뇌저동맥부전이나타날경우추가적인수술을시행하여좌측쇄골하동맥의재관류를하여야한다. 본연구에서도흉부컴퓨터단층촬영에서좌우척추동맥의크기를비교하여좌측척추동맥의크기가같거나굵을경우최대한좌측쇄골하동맥을보존하려고하였다. 3례에서는 Chimney graft technique을이용하여좌측쇄골하동맥혈의흐름을보존하였고, 1례에서 Debranching을시행하였으며, 1례에서쇄골하동맥- 경동맥우회술을시행하여좌측쇄골하동맥의혈류를보존하였다. 2례에서좌측쇄골하동맥을덮었으나 2례중 1례에서는시술후 5일에뇌혈관경색으로사망하였고, 나머지 1례에서는그라프트주위유출이지속되어 Amplatzer vascular plug 14 mm를이용하여추가적으로좌측쇄골하동맥혈관내색전술을시행하였다. 이에좀더정확한좌우척추동맥의우세성을확인하는방법이필요할것으로사료된다. 젊은환자에서상대적으로좁은대동맥크기와급한대동맥휘어짐으로인해스텐트그라프트의찌그러짐이발생할수있는데이것은너무큰스텐트그라프트를삽입하거나, (30,31) 새부리틈새 (bird s beak gap) 가생긴경우이다.(30,32,33) 새부리틈새가발생하면고압의대동맥혈류 로스텐트그라프트와대동맥벽사이의틈새가더커지게된다.(34) 결국스텐트그라프트주위유출이발생하면유출부압력에의해스텐트그라프트가찌그러진다.(32,33) 유출부위가작으면증상이없을수있지만, 유출부위가클경우하행대동맥으로의혈류량이감소하여생명까지위협할수있다.(32) 본연구에서는시술직후 1형그라프트주위누출이발생한적은있었으나, 대동맥폐쇄풍선 (Reliant stent graft balloon catheter, Medtronic Cardiovascular, Sunrise, Fla) 으로모두해결가능하였다. 추가적인스텐트혹은스텐트그라프트를원위부에삽입한적은없었다. 앞에서설명했듯이좌측쇄골하동맥으로부터의 2형그라프트주위누출이발생하여좌측쇄골하동맥색전술을시행한바는있었다. TEVAR 시술시가장많이발생하는합병증은시술을위한혈관접근시이용하는대퇴및장골동맥의손상인데,(29) 본연구에서는발생하지않았다. 다른합병증으로는스텐트의접힘, 스텐트의이동, 스텐트의골절이보고되고있으며, 장기적으로추적관찰을하면대동맥천공, 대동맥박리, 가성대동맥류형성등의발생여부를확인하여야한다. 몇몇보고된논문에서 TEVAR의시술과관련된사망률은 2%, 30일사망률은 8% 를보고하고있다.(36) 또한 David G. 등의보고에선 20명의 TEVAR를시행한환자에서 4명의사망과 1명의환자에서그라프트의폐쇄를보고하였다.(37) 또한장골동맥의파열과그라프트주위유출도 4.2% 에서보고하고있다.(38) 본연구결과에서도좌측쇄골하동맥을가린 1명의환자에서 5일후에뇌경색으로사망한예이외에시술과관련된합병증은발생하지않았다. A B Fig. 3. Surgical procedure : The ascending aortic branches are dissected. A prostheses is anastomosed end-to-end at the ascending aorta to brachiocephalic artery. Left carotid artery is anastomosed end-to-end at the prosthetic brachiocephalic artery. Left subclavian artery is transposed to left carotid artery. (A) Postoperative computed tomography scanning shows TEVAR and debranching (3-demensional reconstructions). (B) Cartoon showing the surgical anastomosis to ascending aorta. 238

Gwan Woo Ku, et al.: Clinical Analysis of TEVAR in Blunt Thoracic Aortic Injury V. 결론 본연구에서는흉부둔상으로발생한흉부대동맥손상에대한혈관내치료의성적을분석하였으며, TEVAR 술식의우수한단기성적을보였다. 현재 TEVAR에대한많은연구가보고되고있으나 TEVAR의시행이 2000년이후본격적으로이루어지고있으므로 TEVAR의궁극적인치료결과에대한장기성적에대한전향적연구가필요한것으로사료된다. REFERENCES 01) Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients-has anything changed? Injury 2009; 40: 907-11. 02) Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med. 2008; 359: 1708-16. 03) Pierangeli A, Turinetto B, Galli R, Calderata L, Fattori R, Gavelli G. Delayed treatment of isthmic aortic rupture. Cardiovasc Surg. 2008; 8: 280-3. 04) Gammie JS, Shah AS, Hattler BG, Kormos RL, Peitman AB, Griffith BP, Pham SM. Traumatic aortic rupture: Diagnosis and management. Ann Thorac Surg 1998; 66: 1295-300. 05) Ferrari E, Tozzi P, von Segesser L. Thoraicc aorta emergencies: is the endovascular treatment the new gold standard? 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