대한영상의학회지 2010;63:365-370 복부대동맥류와복부장기악성종양에동시에이환된환자의혈관내스텐트삽입결과 : 초기경험 1 최유리 신효현 2 임남열 3 오현준 2 장남규 김재규 2 최수진나 4 정상영 4 목적 : 복부대동맥류와복부장기악성종양에동시에걸린환자에서복부대동맥류에대해시행한인조혈관스텐트삽입술의초기경험에대해평가하고자하였다. 대상과방법 : 복부대동맥류와복부장기악성종양으로인조혈관스텐트삽입술과종양에대한수술적치료를받은환자 12명을연구대상으로하였으며, 이중 8명은수술전에스텐트를삽입하였고 4명은수술후에삽입하였다. 나이는 53-82세 ( 평균 71세 ) 이며남자 11명, 여자 1명이었다. 복부장기악성종양종류는위, 결장직장, 췌장, 전립선, 담낭등이었다. 추적관찰기간은 3-21개월 ( 평균 11.8개월 ) 로전산화단층동맥조영술또는색도플러초음파로검사하였다. 결과 : 12명환자모두에게성공적으로인조혈관스텐트삽입술을시행하였으며, 인조혈관스텐트삽입술과종양수술과의시간간격은 6일에서 180일 ( 평균 58.6일 ) 이였다. 추적관찰기간도중 2명 (17%) 의환자에서제2형내강누출이있었다. 췌장암환자 1명에서수술받은 20일후급성성인호흡곤란증후군이발생하여회복가능성없어퇴원하였다. 시술관련사망이나스텐트감염등은없었다. 결론 : 복부대동맥류와복부장기악성종양에동시에걸린환자에서복부대동맥류에대한인조혈관스텐트삽입술을이용한혈관내중재적치료법은낮은사망률과적은합병증을보이며, 두질환을동시에갖는환자에서치료계획을세우는데있어도움을줄것으로생각한다. 복부대동맥류와복부장기악성종양이동시에발병될확률은 3.9~12.6% 로비교적흔하지않은것으로알려져있으나 (1), 중 장년층인구가늘어감에따라연령관련질환, 즉복부대동맥류와악성종양환자가늘어나고있으며, 따라서두질환에동시에걸린환자또한증가할것으로예상한다 (2, 3). 두질환이공존하는경우임상치료전략의초점은두질환을단계적으로치료할것인가혹은동시에치료할것인가를결정하는것이며, 단계적으로치료한다면어떤질환을먼저치료하는것이예후에좋을지를판단하는것이다 (4). 복부종양을먼저치료하는경우에복부대동맥류파열의위험성이증가할수있고 (2, 3), 복부대동맥류를먼저치료하는경우는악성종양의수술을연기해야하는부담과이미시행한인조혈관에감염이생길위험성이증가하게된다 (4). 현재까지두질환이동시에걸린환자의치료에대한무작위대규모연구가없는실정이며확립된치료기준또한없다 (4). 1 화순전남대학교병원영상의학과 2 전남대학교병원영상의학과 3 국군양주병원영상의학과 4 전남대학교병원외과학과이논문은 2010년 2월 17일접수하여 2010년 6월 20일에채택되었음. 365 이에본연구에서는복부대동맥류에대해인조혈관스텐트삽입술 (Endovascular aneurysmal repair, 이하 EVAR) 을받고복부장기악성종양으로수술적치료를받은환자에대한치료결과를분석 보고하고자한다. 대상과방법 2006년 3월부터 2009년 8월까지복부대동맥류로본원에서 EVAR를시행받은 66명의환자에대해후향적연구를시행하였으며, 16명 (16/66, 24%) 에서악성종양이동반되었다. 그중복부장기종양이아닌경우 (n=1), 복부대동맥류와종양이동시에존재하지않았던경우 (n=2), 또종양에대해수술적치료를하지않은경우 ( 항암치료나방사선치료를받은환자, n=1) 는연구대상에서제외하였다. 복부대동맥류에대해 EVAR를받고, 복부장기종양에대해수술적치료를받은환자 12명 ( 남자 11명, 여자 1명, 연령분포 53-82세, 평균연령 71세 ) 을연구대상으로하였다. 종양이발생한복부장기는위, 결장직장, 췌장, 전립선, 담낭등이었다 (Table 1). 모든환자는 EVAR전복부전산화단층동맥조영술
최유리외 : 복부대동맥류와복부장기악성종양에동시에이환된환자의혈관내스텐트삽입결과 (Somatom Sensation Cardiac 64, Siemens, Forchheim, Germany) 를시행하였으며, Eurostar registry의 work sheet를이용하여복부대동맥류의해부학적인정보를얻고, 이를바탕으로인조혈관스텐트를선택하였다. 환자에대한자료는의무기록과영상검사를바탕으로수집하였으며, 나이, 성별, 복부장기종양 ( 종류, 병기, 치료방법 ), 진단당시동맥류크기, 인조혈관스텐트종류, 추적관찰기간, 동맥류크기변화, 종양수술과동맥류시술사이시간간격, 시술후부작용, 수술후부작용, 시술전 후치사율, 생존결과를조사하였다. EVAR 후영상추적관찰은 1주, 1개월, 3개월, 6개월간격으로복부전산화단층동맥조영술을시행하도록권고하였으며, 6개월후추적관찰은 color Doppler US로시행하였다. 결과복부대동맥류에대한 EVAR는 12명환자에게서모두성공적으로이루어졌으며, 수술적전환은없었다. 12명환자모두진단당시복부대동맥류에의한증상은없었으며, 시술전 후대동맥류파열은없었다. 내시경이나직장내시경을통해복부종양을먼저진단받고병기결정을위해시행한복부 CT에서우연히복부대동맥류를발견한환자가 8명, 복부대동맥류를진단받고추적관찰도중복부장기종양을발견한환자가 2명, 건강상태확인을위해시행한복부전산화단층촬영에서복부장기종양과복부대동맥류를동시에진단받은환자가 2명이었다. 12명환자중 EVAR를먼저시행받은환자는 8명, 종양에대한수술을먼저시행받은환자는 4명이었다. EVAR 시행받은날과종양수술날짜사이의평균간격은 58.6일이었다. Table 1. Patient Demographics Patient* Age/Sex Organ of Cancer Stage Name of Surgery** 01 71 M Rectum IIA T3N0Mx LAR 02 75 M Rectum IIIB T4N1M0 LAR 03 65 M Rectum IIIC T3N2M0 S-colostomy + CCRT 04 71 M Rectum IIA T3N1Mx RHC 05 66 M GB IIB T2N0Mx LCS 06 68 M Pancreas IIB T3N1Mx PPPD 07 73 M Stomach II T2N1Mx RSG 08 74 M Pancreas IIB T3N1Mx PPPD 09 79 M Prostate IB T3N0Mx TUR-P 10 82 F Stomach IB T2N0Mx RSG 11 75 M Rectum I T1N0Mx EMR 12 53 M Rectum I T2N0Mx Trans anal mass excison + CCRT Note. * First 8 people written bold stroke were the patient underwent EVAR first, followed by operation for abdominal neoplasia. ** LAR = low anterior resection, CCRT = concomitant chemoradiation therapy, RHC = right hemi-colectomy, LCS = laparoscopic cholecystectomy, PPPD = pylorus-preserving pancreatoduodenectomy, TUR-P = transurethral resection of the prostate, RSG = radical subtotal gastrectomy, EMR = endoscopic mucosal resection Table 2. Long-term Results Aneurysm Interval Post op EVAR Outcomes Patient Size (mm) (day) Complication Complication (month) 366 Device 01 41.5 010 Loss (15) Excluder 02 32.3 045 Alive (17) Zenith 03 55.0 096 Alive (10) Excluder 04 37.6 060 Alive (10) Zenith 05 46.1 048 Alive (10) Zenith 06 50.0 045 Alive (10) Zenith 07 74.0 146 Type 2 endoleak Alive (11) Zenith 08 62.7 024 ARDS Hopeless D/C Excluder 09 61.0 029 Alive (21) Zenith 10 47.0 180 Loss (15) Zenith 11 74.4 006 Alive (3) Excluder 12 37.2 014 Type 2 endoleak Alive (6) Excluder Mean 51.6 58.6 Note. Interval: day between EVAR and malignancy surgery or between malignancy surgery and EVAR Excluder (Gore), Zenith (Cook)
대한영상의학회지 2010;63:365-370 시술후입원기간은 3~8일 ( 평균 5.5일 ) 이었다. 12명모두에게서복부대동맥류파열이나인조혈관스텐트감염사례는없었다. 시술후심폐기능저하나신부전등의주요합병증이발생한경우는없었다. EVAR를먼저시행받고 24일후췌장암수술받은 1명에서수술 20일후급성성인호흡부전과다장기기능부전으로회복가망없이외부병원으로전원되었다 (Table 2). 시술후 2명의환자에서제2형내강누출이발생했으며, 1명은추적관찰전산화단층촬영에서사라졌음을확인하였고, 나머지 1명은누출량이적어서특별한치료없이추적 관찰중이다. 고찰복부대동맥류와복부장기종양을동시에갖는환자에서이상적인치료전략을확립하는것은여전히논란의여지가있다 (1, 2, 5-8). 대부분임상의사들은증상이있거나혹은더치명적인병변에치료의우선순위를둬야한다는데에동의한다 (2, 8-10). 하지만, 두질환을동시에갖는환자대부분이진단당시특별한증상이없어서임상의사들은수술적치료가 A B Fig. 1. 73-year-old male with gastric malignancy involving antrum. A. Contrast enhanced abdomen CT scan show irregular wall thickening in gastric antrum on coronal image (black arrow). The cancer is detected incidentally during abdominal aortic aneurysm follow up. B. Maximal diameter of AAA is increased from 53 mm to 74 mm on volume rendering image (white arrow head). C. Post-EVAR angiogram reveals well functioning endograft. C 367
최유리외 : 복부대동맥류와복부장기악성종양에동시에이환된환자의혈관내스텐트삽입결과 필요하지만, 치명적위험성이있는이두질환의치료계획을세우는데어려움을겪게된다. 복부종양을먼저제거하고복부대동맥류를치료하는경우, 특히동맥류직경이 5 cm가넘는경우는잠재적인동맥류파열위험성이있다. 반면대동맥류수술을먼저하고복부종양수술을하는경우적절한종양치료시기를놓쳐종양의주변부파급혹은전신적인전이가생길수있다. 단계적인수술로인한스트레스는심혈관계이환율을높일수도있고환자나보호자의불안감을증가시킬수있다 (2). 복부대동맥류와복부장기종양을수술적방법으로동시에치료하는것은현재까지비교적성공적이라고하나 (11-13), 가장큰문제는장내세균에의한인조혈관감염이다. EVAR 는기술과장비, 그리고축적된경험의발달로대동맥박리, 동정맥샛길, 종양침입등여러상황에서이용되고있으며, 수술과관련된질병률과사망률을줄일수있어수술적치료를대체할수있는치료법으로서시술사례가증가하고있다 (13). EVAR 시술은감염된혹은오염된수술공간에노출될위험이없어서감염과관련된합병증이매우낮다 (5, 14-17). 실제로 Sharif 등 (6) 에따르면, EVAR의패혈증관련합병증은 0.39% 로개복수술의 1.3% 보다낮은수치를보였다. EVAR는두질환이동시에있는환자의치료전략을세우는데큰도움을줄수있다 (2, 5, 14, 18). EVAR는수술과전신마취에대한부담이없고, 입원기간이짧으며, 시술전후사망률과이환율이매우낮고, 수술도중대동맥류파열에대한불안감을없애줄수있다 (2, 18). Lin 등 (2) 은복부대동맥 5.5일이였으며, 시술후시술관련합병증으로인해종양수술이연기되는사례는없었다. 복부대동맥류의파열이나인조혈관감염사례의경우도없었다. 또한, 축적된경험과기술의발달로과거에해부학적으로적합하지않다고여겨졌던증례에서도합병증없이성공적으로 EVAR를시행하였고, 따라서해부학적인문제가스텐트삽입술에큰제한점이되지못할것으로생각한다 (9). 본원에서 EVAR 후 10일만에대장암수술을받은경우가있었다. EVAR후적합한수술시기는 EVAR에대한특별한합병증이없고, 전신마취에대한수술전검사에서특별한이상이없는경우 10일후에도가능할것으로생각한다. 현재까지두질환이공존하는경우에어떤치료전략이더좋은지에대한대규모연구는없다. 두질환이동시에걸리는경우는연구기관에따라보고된발병률이다양하며, 본원은 24% 로높은발병률을보였다. 고령화사회로진행될수록이러한임상상황을접할기회는더많아질것으로생각하며, 따라서두질환이공존하는경우치료법에관한무작위대규모연구가반드시필요할것으로생각한다. 본연구의제한점은연구대상그룹이작다는것과, 복부대동맥류와복부종양을동시에갖는환자에서 EVAR를시행한경우와대동맥류에대해개복수술을시행한경우를비교하지않았다는점이다. 결론적으로 EVAR는복부대동맥류와복부악성종양을같이갖는환자에서안전한시술이며, 두질환을치료하는데있어치료전략을세우는데큰도움을줄수있다. 류와결장직장암이동시에걸린 108명의치료과정을분석한결과 5개의그룹중 EVAR를먼저시행하고단계적으로결장직장암절제술을받은그룹에서수술후합병증과수술중출 참 고 문 헌 혈이감소하였으며, 입원기간또한짧았다고하였다. 또 1. Lee JT, Donayre CE, Walot I, Kopchok GE, White RA. Endovascular exclusion of abdominal aortic pathology in patients EVAR 후빠른신체회복으로단계적결장직장암절제술받기 with concomitant malignancy. Ann Vasc Surg 2002;16:150-156 까지가장짧은경과시간을보였다. Lin 등 (2) 은복부대동맥 2. Lin PH, Barshes NR, Albo D, Kougias P, Berger DH, Huynh TT, et 류의크기가 5 cm 이상이거나복부종양과관련하여생명에큰위협이될만한증상이없는경우에 EVAR후단계적종양절제치료가효과적이고, EVAR에적합하지않은해부학적으로불리한동맥류목을가졌으면개복하여복부대동맥류를치료하는것이바람직하다고하였다 (16). al. Concomitant colorectal cancer and abdominal aortic aneurysm: evolution of treatment paradigm in the endovascular era. J Am Coll Surg 2008;206:1065-1075 3. Shalhoub J, Naughton P, Lau N, Tsang JS, Kelly CJ, Leahy AL, et al. Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature. Eur J Vasc Endovasc Surg 2009;37:544-556 EVAR로인해수술이연기되는경우는없었으나 3명의환 4. Baxter NN, Noel AA, Cherry K, Wolff BG. Management of patients with colorectal cancer and concomitant abdominal aortic 자에서 EVAR와수술간격이 3개월이상으로길었다. 이들중 한명은 EVAR후대장암에대한항암치료와방사선치료로인해수술시기가늦어졌으며, 한명은 EVAR후생긴반복된기 aneurysm. Dis Colon Rectum 2002;45:165-170 5. Rivolta N, Piffaretti G, Tozzi M, Lomazzi C, Riva F, Alunno A, et al. Management of simultaneous abdominal aortic aneurysm and 흉에대한치료로수술이늦어졌다. 또한명은위암수술당시 colorectal cancer: the rationale of mini-invasive approach. Surg 최대 47 mm 직경의복부대동맥류가있었으나치료하지않다 Oncol 2007;16 Suppl 1:S165-S167 가약 5개월후에시행한복부전산화단층촬영에서대동맥류직경이 57 mm로증가하여뒤늦게 EVAR를시행받았다. 6. Sharif MA, Lee B, Lau LL, Ellis PK, Collins AJ, Blair PH, et al. Prosthetic stent-graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2007;46:442-448 EVAR후수술시기가길어진 3명의환자에대해서수술전전 7. Matsumoto K, Murayama T, Nagasaki K, Osumi K, Tanaka K, 산화단층촬영을시행하여암병기진단을다시하였다. Nakamaru M, et al. One-stage surgical management of concomitant 본원에서는동시에두질환을갖는환자에있어서 EVAR를먼저시행하고후에종양에대한단계적수술치료를하는것을선호한다. EVAR 시행받은환자들의평균재원기간은 abdominal aortic aneurysm and gastric or colorectal cancer. World J Surg 2002;26:434-437 8. Bastounis E, Felekouras E, Arvelakis A, Georgopoulos S, 368
대한영상의학회지 2010;63:365-370 Griniatsos J, Papalambros E. Abdominal aortic aneurysm and hepatocellular carcinoma: a one-stage approach. HPB (Oxford) 2002; 4:195-197 9. Kiskinis D, Spanos C, Efthimiopoulos G, Saratzis N, Lazaridis I, Gkinis G. Priority of resection in concomitant abdominal aortic aneurysm (AAA) and colorectal cancer (CRC): review of the literature and experience of our clinic. Tech Coloproctol 2004;8:19-21 10. Komori K, Okadome K, Itoh H, Funahashi S, Sugimachi K. Management of concomitant abdominal aortic aneurysm and gastrointestinal malignancy. Am J Surg 1993;166:108-111 11. Onohara T, Orita H, Toyohara T, Sumimoto K, Wakasugi K, Matsusaka T, et al. Long-term results and prognostic factors after repair of abdominal aortic aneurysm with concomitant malignancy. J Cardiovasc Surg (Torino) 1996;37:1-6 12. Pedrazzani C, Veraldi GF, Tasselli S, Tomasi I, Bernini M, Giacopuzzi S, et al. Surgical treatment of gastric cancer with coexistent abdominal aortic aneurysm. Personal experience and literature review. Hepatogastroenterology 2006;53:973-975 13. 이도연. 복부대동맥류의혈관내치료법. In 대한인터벤션영상의학 회. 인터벤션영상의학. 서울 : 일조각, 2007:292-301 14. Illuminati G, Calio FG, D Urso A, Lorusso R, Ceccanei G, Vietri F. Simultaneous repair of abdominal aortic aneurysm and resection of unexpected, associated abdominal malignancies. J Surg Oncol 2004;88:234-239 15. Swanson RJ, Littooy FN, Hunt TK, Stoney RJ. Laparotomy as a precipitating factor in the rupture of intraabdominal aneurysms. Arch Surg 1980;115:299-304 16. Durham SJ, Steed DL, Moosa HH, Makaroun MS, Webster MW. Probability of rupture of an andominal anortic aneurysm after an unrelated operative procedure: a prospective study. J Vasc Surg 1991;13:248-252 17. Trede M, Storz LW, Petermann C, Schiele U. Pitfalls and progress in the management of abdominal aortic aneurysm. World J Surg 1988;12:810-817 18. Porcellini M, Nastro P, Bracale U, Brearley S, Giordano P. Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy. J Vasc Surg 2007;46:16-23 369
최유리외 : 복부대동맥류와복부장기악성종양에동시에이환된환자의혈관내스텐트삽입결과 J Korean Soc Radiol 2010;63:365-370 Endovacular Exclusion of an Abdominal Aortic Aneurysm in Patients with Concomitant Abdominal Malignancy: Early Experience 1 You Ri Choi, M.D., Hyo Hyun Shin, M.D. 2, Nam Yeol Yim, M.D. 3, Hyun-Jun Oh, M.D. 2, Nam Kyu Chang, M.D., Jae Kyu Kim, M.D. 2, Soo Jin Na Choi, M.D. 4, Sang Young Chung, M.D. 4 1 Department of Radiology, Chonnam National University Hwasun Hospital 2 Department of Radiology, Chonnam National University Hospital 3 Department of Radiology, The Armed Forces Yangju Hospital 4 Department of Surgery, Chonnam National University Hospital Purpose: To assess the outcomes of endovascular aortic aneurysm repair (EVAR) for the treatment of an abdominal aortic aneurysm in patients undergoing curative surgical treatment for concomitant abdominal malignancy. Materials and Methods: The study included 12 patients with abdominal neoplasia and an abdominal aortic aneurysm (AAA), which was treated by surgery and stent EVAR. The neoplasm consisted of the gastric, colorectal, pancreas, prostate, and gall bladder. The follow up period was 3-21 months (mean 11.8 months). All medical records and imaging analyses were reviewed by CTA and/or color Doppler US, retrospectively. Results: Successful endoluminal repair was accomplished in all twelve patients. The mean interval time between EVAR and surgery was 58.6 days. Small amounts of type 2 endoleaks were detected in two patients (17%). One patient developed adult respiratory distress syndrome after Whipple s operation 20 days after surgery, which led to hopeless discharge. No procedure-related mortality, morbidity, or graft-related infection was noted. Conclusion: Exclusion of AAA in patients with accompanying malignancy show with a relatively low procedure morbidity and mortality. Hence, endoluminal AAA repair in patients with synchronous neoplasia may allow greater flexibility in the management of an offending malignancy. Index words : Aortic Aneurysm Abdominal, Angioplasty Neoplasm/Complication Blood Vessel Prosthesis Implantation Address reprint requests to : Nam Kyu Chang, M.D., Department of Radiology, Chonnam National University Hwasun Hospital 160, Ilsim-ri, Hwasun-eup, Hwasun-gun, Jeollanam-do 519-763, Korea. Tel. 82-61-379-7112 Fax. 82-61-379-7133 E-mail: tosouth9@hanmail.net 370