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A B C Fig. 1. Deep vein thrombosis of left lower extremity in 48-years-old female. A. After removal of iliofemoral vein thrombus, Initial venography shows impacted thrombus with obstruction in the popliteal and tibial veins. B. Follow-up venography show the complete removal of thrombus and restored venous flow after 2-days catheter-directed infusion of urokinase. C. 18 months follow-up venography show patent lumen and venous flow without recurrent thrombosis in the popliteal and tibial veins. 122
대한영상의학회지 2008;58:121-125 시작하였다. 정맥조영술을 통하여 혈전제거, 혈류의 흐름을 확인하고 혈 전용해제 주입을 중단하기로 하면 카테터를 즉시 제거하였고 천자부위의 혈액 누출을 예방하기 위하여 봉합 하였다. 혈관 내 인터벤션을 마친 후에 6개월 이상 항응고요법을 시작하였 고 CT와 상행 정맥조영술의 추적검사를 시행하여 정맥의 개 존 여부와 혈전 재발을 확인하였다. 결 과 11명 모든 환자에서 성공적으로 초음파 유도하에 오금정맥 의 상부를 천자하여 카테터를 삽입하였고 유로키나제를 주입 하여 오금정맥과 정강정맥의 혈전을 제거해서 혈류의 회복을 시도할 수 있었다. 시술 직후 10명에서는 혈전이 제거되어 혈 류의 흐름이 잘 유지되어 있었으나, 1명에서는 7일 후 검사에 서 혈전이 재발하였으나 혈류의 흐름은 어느 정도 유지되고 있었다. 결국, 11명 대상에서 10명에서 시술직후 성공을 거둘 수 있었다. 장골대퇴정맥의 혈전을 제거하였기 때문에 소용량의 유로키 나제를 시간당 3만 단위를 주입하였고 주입시간은 평균 2.36 일(1일 - 4일)이며 평균 170만 단위를 추가로 주입하였다. 일 부의 장골대퇴 정맥의 혈전이 남아있었고 정강정맥은 3쌍 총 6개의 분지로 구성되어 있어서 유로키나제의 주입시간이 예상 보다 길었다. 혈전용해제의 효과가 미약하여 혈전제거가 지연 되는 많은 양의 오래된 혈전은 혈전흡입제거술이 효과적이었 다. 11명 환자 중 4명에서 부분적인 정맥의 협착이 발견되었다. 3예에서는 오금정맥, 1예는 총대퇴정맥, 1예는 대퇴정맥에서 협착이 관찰되었다. 혈전이 재발한 환자에서는 총대퇴정맥과 오금정맥에 국소적인 혈류의 협착이 발견되었고 협착부위 때 문에 혈류의 흐름이 방해되어 혈전이 재발하였다. 정맥의 부 분적인 협착은 정맥혈전이 오랫동안 경과되어서 정맥벽 자체 에 변화가 오고 협착이 진행된 경우로 판단되었다. 결국, 혈전 을 제거하고 혈류의 흐름이 원활히 회복되지 못하는 경우에는 오금정맥과 대퇴정맥에 부분적인 정맥협착을 확인할 필요가 있다. 15.2개월(8-28개월) 동안 CT, 상행정맥조영술을 이용하여 추적검사를 통하여 혈전의 재발 여부, 오금정맥과 정강정맥의 개통성 유무를 확인하였다. 모든 환자에서 재발성 혈전증은 발 생하지 않았고 오금정맥은 개통되어 있으며 혈류 흐름을 유지 A B C Fig. 2. Deep vein thrombosis of left lower extremity in 30-years-old male. A. After removal of iliofemoral vein thrombus, Initial venography shows complete occlusion with thrombus of the popliteal and tibial veins. B. Follow-up venography show the restored venous flow through the residual thrombus in the popliteal and tibial vein after 4-days catheter-directed infusion of urokinase. C. 18 months follow-up venography show patent lumen and venous flow with slight residual thrombus in the popliteal and tibial veins. 123
1. Sharafuddin MJ, Shiliang Sun, Hoballah JJ, Youness FM, Sharp WJ, Roh BS. Endovascular management of venous thrombotic and occlusive diseases of the lower extremities. J Vasc Interv Radiol 2003;14:405-423 2. Semba CP, Dake MD. Iliofemoral deep venous thrombosis: Aggressive therapy with catheter-directed thrombolysis. Radiology 1994;191:487-494 3. Bjarnason H, Kruse JR, Asinger DA, Nazarian GK, Dietz CA, Caldwell MD, et al. Iliofemoral deep venous thrombosis: safety and efficacy outcome during 5years of catheter-directed thrombolytic therapy. J Vasc Interv Radiol 1997;8:405-418 4. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology 1999;211:39-49 5. Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous throm- improves health-related quality of life. J Vasc Surg 2000;32: bosis 130-137 6.,,,,,,. :. 2000; 43:291-297 7. Ohgi S, Tachibana M, Ikebuchi M, Kanaoka Y, Maeda T, Mori T. Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology 1998;49:759-764 8. Mattos MA, Melendres G, Sumner DS, Hood DB, Barkmeier LD, Hodgson KJ, et al. Prevalence and distribution of calf vein thrombosis in patients with symptomatic deep venous thrombosis: a col- or-flow duplex study. J Vasc Surg 1996;24:738-744 9. Hill SL, Holtzman GI, Martin D, Evans P, Toler W, Goad K. The origin of lower extremity deep vein thrombi in acute venous thrombosis. Am J Surg 1997;173:485-490 10. Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed 124
deep vein thrombosis. Am J Cardiol 2004;93:259-262 11. Masuda EM, Kessler DM, Kistner RL, Eklof B, Sato DT. The natural history of calf vein thrombosis: Lysis of thrombi and development of reflux. J Vasc Surg 1998;28:67-74 12. MacDonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg 2003;37:523-527 13. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985;2:515-518 14. Deitcher SR, Caprini JA. Calf deep venous thrombosis should be treated with anticoagulation. Med Clin North Am 2003;87:1157-1164 15. McLafferty RB, Moneta GL, Passman MA, Brant BM, Taylor LM, Porter JM. Late clinical and hemodynamic sequelae of isolated calf vein thrombosis. J Vasc Surg 1998;27:50-57 16. Saarinen J, Domonyi K, Zeitlin R, Salenius JP. Post-thrombotic symptoms after an isolated calf deep venous thrombosis. J Cardiovasc Surg 2002;43:687-691 17. Saarinen JP, Domonyi K, Zeitlin R, Salenius JP. Postthrombotic syndrome after isolated calf deep venous thrombosis: The role of popliteal reflux. J Vasc Surg 2002;36:959-964 18. Sharpe RP, Gupta R, Gracias VH, Pryor JP, Pieracci FM, Reilly PM, et al. Incidence and natural history of below-knee deep venous thrombosis in high-risk trauma patients. J Trauma 2002;53: 1048-52 19. Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Moutzouros V, Baker WH. Early thrombus remodelling of isolated calf deep vein thrombosis. Eur J Vasc Endovasc Surg 2002;23:344-48 Catheter-directed Thrombolysis of Below-Knee Deep Venous Thrombosis of the Lower Extremities 1 Byung-Suk Roh, M.D., Young Jun Sohn, M.D., Eun-A Heo, M.D., Hyun Sun Cho, M.D., Seong Hoon Park, M.D., Young Hwan Lee, M.D. 1 Department of Radiology, Wonkwang University Hospital Purpose: To evaluate the technical feasibility and clinical efficacy of the use of local thrombolysis for belowknee deep vein thrombosis (DVT). Materials and Methods: From a population of 41 patients with a lower extremity DVT, the prospective clinical trial included 11 patients (7 female, 4 male, average age 61.4 years) treated with catheter-directed thrombolysis with urokinase for below-knee DVT. After removal of the proximal ilofemoral DVT, additional interventional procedures to remove the residual thrombus and restore the venous flow from the below-knee vein were performed in cases of continuous occlusion of venous flow from the popliteal and tibial veins. Under ultrasound (US) guidance, catheter-directed thrombolysis with urokinase was performed through the ipsilateral popliteal vein. After administration of oral anticoagulation therapy, CT and venography were performed to identify patency and the presence of a recurrent thrombosis. Results: Successful removal of the thrombus and restoration of venous flow were achieved in all of the patients (100%). Restoration of flow with a residual thrombus occurred in one case. Focal venous stenosis was discovered in four cases. The duration of urokinase infusion was 1 4 days (average 2.36 days), which was considered long. For 15.2 months, the venous lumen of all cases was preserved without a recurrent thrombosis. Conclusion: Catheter-directed thrombolysis is an effective procedure for recanalization of below-knee DVT in patients with a lower extremity DVT. Index words : Venous thrombosis Thrombolytic therapy Lower extremity Address reprint requests to : Byung-Suk Roh, M.D., Department of Radiology, Wonkwang University Hospital 344-2 Shinyong-dong, Iksan, Chonbook 570-711, Korea. Tel. 82-63-859-1922 Fax. 82-63-851-4749 E-mail: bsroh@wonkwang.ac.kr 125