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대한혈관외과학회지 : 제 24 권제 2 호 Vol. 24, No. 2, November, 2008 Takayasu 동맥염에대한수술적치료 가톨릭대학교의과대학외과학교실혈관이식외과 차유선ㆍ윤상섭ㆍ최승혜ㆍ김상동ㆍ박순철ㆍ김지일ㆍ원용성ㆍ문인성ㆍ박장상ㆍ고용복 Surgical Treatments for Takayasu s Arteritis Yu Sun Cha, M.D., Sang Seob Yun, M.D., Seung Hye Choi, M.D., Sang Dong Kim, M.D., Sun Cheol Park, M.D., Ji Il Kim, M.D., Yong Sung Won, M.D., In Sung Moon, M.D., Jang Sang Park, M.D. and Yong Bok Koh, M.D. Division of Vascular and Transplant Surgery, Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea Purpose: Takayasu s arteritis (TA) is a chronic inflammatory, stenotic or aneurysmal disease of an unknown etiology. TA occurs worldwide, but it disproportionately affects young females of Asian descent. TA is known to affect a variety of vessels, but the subclavian artery, axillary artery, carotid arteries and infraabdominal aorta are most frequently affected. In this article, we evaluated surgical treatment as a modality for the management for TA. Method: We retrospectively reviewed 20 patients with TA and who were operated on from January 1994 to December 2007. Result: The ages of patients were ranged from 12 to 56 years. The ratio of males to females was 1 to 19. The main affected vessels were the subclavian artery (n=10), the common carotid artery (n=10), the abdominal aorta (n=4) and the renal artery (n=4). 20 patients with TA were operated on. 17 of them underwent arterioarterial bypass, and 5 patients received angioplasty. There were 8 cases of reoperation due to the effect on other arteries, or due the stenosis or occlusion of the previous bypass graft. Angioplasty and stenting can be used in the treatment of shorter stenoses such as those encountered in the renal arteries. Conclusion: Symptomatic patients who have Takayasu s arteritis can be operated on. Our surgical experiences have showed low mortality and the surgical procedures relieved the symptoms. Surgical therapy for Takayasu s arteritis was safe and it showed good results. Key Words: Takayasu s arteritis, Surgical treatment 중심단어 : Takayasu 동맥염, 수술적치료 서 Takayasu 동맥염은대동맥과그분지및폐혈관에염증성반응을일으켜다양한증상을일으키는질환이다. 이질환은만성적이며, 임상증상은침범된혈관에따라전신적인것에서국소적인것까지다양하다 (1,2). Takayasu 동맥염의치료로약물치료를우선적으로시행하나 (3), steroid나 antiinflammatory 제제등의약물치료로호전되지않고진행되 책임저자 : 박순철, 서울시서초구반포동 505 번지우 137-040, 강남성모병원혈관이식외과 Tel: 02-590-2497, Fax: 02-595-2992 E-mail: sun60278@catholic.ac.kr 론 는경우와협착, 폐색, 동맥류로인한허혈및혈전증상의합병증이일어날경우에는혈관성형술 ( 풍선확장술, 스텐트삽입술 ) 과우회로조성술등의수술적치료가필요하게된다 (4,5). 수술시기에대하여 Suzuki 등 (6) 은약물치료후임상증상과 ESR, CRP 등을염증진행의표식자로이용하여만성기에수술하는것을원칙으로삼고있으나, 협심증이나울혈성심부전증등이발생하면병기에관계없이수술하는것을권장하고있다. 이에저자들은 Takayasu 동맥염으로진단받고, 폐색, 협착등의혈관병변이증상과함께발견되어수술을시행받은환자들에대한수술적치료성과를보고하고자한다. 106

차유선외 :Takayasu 동맥염에대한수술적치료 107 대상과방법가톨릭대학교의과대학외과학교실에서 1994년부터 2007 년까지 Ishikawa s criteria(7,8) 에의해 Takayasu 동맥염으로진단받고 steroid나 antiinflammatory 제제등의약물치료로호전되지않고진행되거나, 침범된동맥의폐색또는협착에의한허혈증상이발생한것이적응증이되어수술적치료를받은 20명의환자들을대상으로의무기록을이용하여후향적연구방법으로분석하였다. 결과수술적치료를시행받은환자들의연령은 12세에서 56세까지로평균 31.8±11.1세였고, 여자가 19명 (95.0%), 남자는 1명 (0.5%) 이었다. 처음병원을방문하게된임상증상으로는고혈압이 7명 (35.0%) 으로가장많았고, 특정부위의통증이 4명 (20.0%), 저림증상 3명 (15.0%), 파행 2명 (10.0%), 두통 1명 (5.0%), 운동시호흡곤란 1명 (5.0%), 발열및오한 1명 (5.0%), 실신 1명 (5.0%) 이었다 (Table 1). 증상발현기간은평균 42.2±51.9개월이었고, 1개월에서 20년까지다양했 다. 진단방법은혈관조영술이 15명 (75.0%), 전산화단층촬영술이 4명 (20.0%), 자기공명영상이 1명 (.05%) 이었고, 침범혈관에따른유형별로나누어보았을때, 제 1형이 4명 (20.0%), 제2형 5명 (25.0%), 제3형이 11명 (55.0%) 이었고, 침범된혈관별로보면쇄골하동맥이 10명 (50.0%), 경동맥이 10명 (50.0%), 복부대동맥 4명 (20.0%), 신장동맥 4명 (20.0%) 이었다 (Table 1). 총 20명의환자가수술받았고, 동맥간우회로조성술을시행받은경우가 17명 (85.0%) (Fig. 1, 2), 혈관성형술을시행받은경우는 5명 (25.0%) 이었고, 수술시에 Dacron이 5명 (25.0%), 가 13명 (65.0%), 환자자신의대복재정맥이 5명 (25.0%) 에서이식편으로사용되었다 (Table 2). 염증표지인자로써수술전 ESR은평균 33.5±25.2 mm/h (8 92) 으로측정되고, 수술후 ESR은평균 10.4±4.6 mm/h (2 20) 으로측정되어서통계학적으로유의하게감소된소견을보였다 (P<0.001 by the SAS system for windows V8)(Table 3). 이중다시재수술을받거나중재적방사선시술을병행시행받은사람은 8명 (40.0%) 으로그원인으로는외래에서경과추적관찰중이전에시행한동맥간우회로조성술이식편의협착이나폐색, 혹은또다른혈관에새로운병변이발생했기때문이었다. 1차수술후 2차수술을받기까지의기간은평균 70.8±57.6개월 (8 175) 이었고, 총경 Table 1. Cinical manifestations of Takayasu s arteritis patients be operated Age (years) Sex Chief complaints (%) Affected arteries (%) 12 56 M:F Hypertension (35.0) Subclavian artery (50) Mean:31.8 1:19 Pain (20.0) Common carotid artery (50) Tingling sensation (15.0) Abdominal aorta (20) Claudication (10.0) Renal artery (20) Headache (5.0) Exertional dyspnea (5.0) Fever and chill (5.0) Syncope (5.0) Fig. 1. The photos show the patient of Takayasu s arteritis be operated due to both renal arteries and abdominal aorta lesions. (A) The angiography shows severe stenosis of both renal arteries and abdominal aorta. (B) The photo of operation field shows aortoaortic bypass with Dacron graft (arrow head) and aorto-birenal bypass with autogenous vein graft (arrow).

108 대한혈관외과학회지 : 제 24 권제 2 호 2008 Fig. 2. The photos shows the patient of Takayasu s arteritis be operated due to both subclavian arteries and Lt. common carotid artery lesions. (A) The angiography shows both subclavian arteries and Lt. common carotid artery occlusions. (B, C) The figures of operative field show aorto-lt. common carotid artery (black arrow head) and Lt. subclavian artery bypass with bifurcated Dacron graft (white arrow), and Dacron graft tort. axillary artery bypass with graft (black arrow). 과관찰기간은평균 62.1±52.7개월 (2 197) 이었다 (Table 3). 수술적치료를받은 20명의환자중 1명 (5.0%) 이수술후 30일이내에사망하였으며, 사망한환자는원래 Sheehan 증후군을가지고있던경우로신장동맥협착으로인한고혈압과원래의기저질환으로인한심부전으로사망하였다. 수술후생존율은사망한 1명을제외한 19명즉, 95.0% 로높은생존율을보였다. 고찰 Takayasu 동맥염은대동맥과대동맥주요분지및폐혈관에염증성반응을일으켜서국소적증상에서전신적증상까지다양하게영향을미치는질환이다. 젊은동양여성에서가장흔하게나타나지만, 전세계적으로나타나고있고, 최근에는서양에도그빈도가증가하고있어, 미국에서는해마다백만명당 2.6명의발병률증가를보이고있다 (9). 처음 Takayasu 동맥염에대해보고된것은 1830년 Yamamoto에의해서이며 (10), 1905년에는일본의안과의사인 Mikito Takayasu도일본안과학회에서젊은일본여성의망막기저부이상에대해발표하면서 Takayasu 동맥염에대해언급한바있다 (10). 1920년에는 Takayasu 동맥염의병리학적정의가기술되었고, 1951년에는최종적으로전체적인임상증상과병에대한양상이정의되었다 (11,12). Takayasu 동맥염은만성적이고, 진행성이며, 망막병증, 동맥류형성, 대동맥판역류, 이차성고혈압등을동반한다. 임상증상은침범혈관에따라전신적인것에서국소적인것까지다양하다 (1,2). 임상증상은근육통, 관절통, 발열, 체중감소등으로나타나고, 목동맥통증과같은통증이있을수도있다. 하지만가장흔한통증은협착된혈관으로부터혈액을공급받는부위의허혈및괴사로인해일어나는일과성허혈발작또는뇌졸증, 시력이상, 척추뇌바닥동맥부전, 사지파행, 협심증, 신장혈관부전, 신장혈관고혈압 (renovascular hypertension) 등이있다 (13). 증상은지역별로다르게나타나기도하는데, 예를들면인디아의환자는고혈압, 좌심실비대가나타나는확률이높고, 남자에서도 Takayasu 동맥염이있을수있으며, 일본의환자는상행대동맥류, 대동맥판역류의확률이높으며심한염증반응을나타내고여자에서두드러지게나타난다 (14). 치료받지않은경우대뇌동맥의출혈, 신부전, 심부전, 심근경색, 대뇌동맥의혈전증, 대뇌동맥류의파열등으로사망하게된다. 이때까지발표된보고에서는수술은성공적으로시행되었으나, 수술후다시협착이발생하거나위동맥류가발생하는경우가많았다 (15-23). 병변은혈관이길고, 부드럽고, 부분적으로좁아진소견을보이고, 죽상판형성은거의하지않는다. 폐색이가장흔하며동맥류를보이기도한다 (24-26). 가장흔히침범하는혈관은쇄골하동맥, 액와동맥, 경동맥, 신장동맥, 복부대동맥등이다 (24-28). Takayasu 동맥염의동맥은혈관의 3벽을모두침범하는장기간의섬유화현상으로단단하고두꺼워져있다 (29). 염증반응이심하면주변구조물을침범하여염증성동맥류처럼보일수도있다 (30). 내막은고르지못하게불규칙적인혈관내면을형성한다 (31). 현미경적소견에서급성기의소견은혈관의외피로부터뻗어나가는전동맥염의모습을보이며, 외피에 T-세포와가지세포가침투하고있는모습을볼수있으며, 중간막으로는혈관신생

차유선외 :Takayasu 동맥염에대한수술적치료 109 Table 2. Lesions and operation titles of Takayasu s arteritis patients be operated No Sex Age Lesion Operation title Graft 1 F 19 AA Aorto-aortic, Aorto-renal bypass Dacron 2 F 44 AA Aorto-biiliac bypass Dacron 3 F 36 Lt. CA, Both SA Rt. subclavian-lt. subclavian bypass, Lt. common carotid-lt. subclavian bypass 4 F 20 Lt. CA, Lt. RA Lt. renal artery balloon angioplasty 5 F 42 AA, Rt. AxA, Lt. SA, Lt. CCA Lt. axillary-rt. brachial bypass, Rt. axillary-rt. common iliac bypass 6 F 29 Both RA Aorto-Lt. renal bypass, Aorto-Rt. renal reimplantation 7 F 27 Both RA, TAA Thoracoabdominal aortic bypass, Aorto-birenal bypass GSV Dacron GSV 8 F 30 Lt. RA Aorto-Lt. renal bypass GSV 9 F 30 Lt. RA, Lt. SA Aorto-birenal bypass, Rt. axillo-lt. brachial bypass 10 F 23 Rt. SA, Rt. RA Axillo-axillary bypass, Lt. renal reimplantation, Rt. renal roof patch angioplasty 11 F 49 Both SA, Lt. CCA Aorto-Lt. common carotid bypass, Lt. axilo-rt. axillary bypass 12 F 12 Both SA, TA Axillo-axillary bypass 13 F 56 Both SA, AoA Aorto-bifemoral bypass, Both femoro-popliteal bypass Dacron Dacron 14 F 28 Lt. SA Roof patch angioplasty GSV 15 F 25 Lt. SA, Lt. CCA, Lt. RA Rt. subclavian-lt. subclavian bypass, Rt. subclavian-rt. axillary bypass 16 F 33 Lt. SA, Rt. CCA, Lt. VA Rt. subclavian-lt. axillary bypass, Rt. subclavian-rt. axillary bypass 17 F 40 Lt. SA, Rt. RA Lt. carotid-lt. subclavian bypass 18 F 45 Lt. SA, CeA Axillo-axillary bypass, Abdominal aorta patch angioplasty 19 M 23 Rt. SA Rt. common carotid-subclavian bypass GSV 20 F 26 TAA Thoracoabdominal aortic bypass, Bilateral aorto-renal bypass No = number; AA = abdominal aorta; CA = carotid artery; SA = subclavian artery; RA = renal artery; AxA = axillary artery; CCA = common carotid artery; TAA = thoracoabdominal aorta; TA = thoracic aorta; AoA = aortic arch; VA = vertebral artery; CeA = celiac artery; = polytetrafluororthylene; GSV = greater sphenous vein 이진행되며단핵구가침투하여내피는평활근과섬유모세포가침투한모양을보이며이들은정상보다많은물질들을주변으로분비한다. 시간이지나면서섬유화가진행되고, 콜라겐과탄력소층의파괴가동반하여 3층모두가두꺼워진다 (3). 감염이이러한과정을일으키는주요한인자로알려져있으며, 드물지만결핵, 바이러스감염등이보고되고있다 (32). 진단을위해서는혈관조영술이표준으로사용되고있는데, 최근에는컴퓨터단층촬영을이용한혈관조영술이자주이용된다. Takayasu 동맥염의침범부위에따라여러가 지분류로나누기도한다. 제 1형은대동맥궁과큰혈관을침범하는경우로 20 40% 를차지하고있고심혈관계부전을동반하는경우가많으며, 제2형은중간크기의동맥 ( 흉부대동맥과복부대동맥의내장동맥분지 ) 이상과고혈압을동반하는신장동맥의협착또는폐색이있는경우가해당되며, 제3형은 50 65% 로가장많고대동맥궁과복부대동맥을동시에침범하는경우이며, 제4형은폐동맥병변이포함된경우로 10% 를차지한다 (33). 최근에는초음파검사가 Takayasu 동맥염의조기발견에이용되기도하는데, 초음파에서의병변은침범혈관벽둘레의두꺼워짐과, 중

110 대한혈관외과학회지 : 제 24 권제 2 호 2008 Table 3. Non surgical characteristics of Takayasu s arteritis patients be operated No Preop. ESR (mm/h) Postop ESR (mm/h) Preop. medical treatment Reoperation Interval between 1st and 2nd operation (month) Follow up (month) 1 8 2 + 112 134 2* 13 + 3 75 10 + 3 4 70 14 + 44 5 33 17 + + 175 197 6 22 11 41 7 70 13 72 8 25 9 69 9 12 6 + + 8 50 10 46 20 + 72 79 11 14 11 5 12 34 6 + 105 164 13 92 12 + 54 55 14 8 18 + 14 50 15 14 10 + 26 57 16 40 10 6 17 20 8 + 2 18 23 9 72 19 10 5 38 20 40 7 42 Mean 33.5±25.2 10.4±4.6 62.1±52.7 No = number; Preop. = preoperative; Postop. = postoperative; ESR = erythrocyte sedimentation rate *expire 간반향, 균질한반향을보인다 (34). 컴퓨터단층촬영술은혈관조영술을보완하는방법으로사용되고있고 (35), 자기공명영상은혈관협착부위주변을확인할수있으며혈관벽의두께나부종정도를측정할수있어급성으로증상발생시이전증상과비교분석이가능한장점이있으며, (36), 신부전환자나임산부처럼신장독성약물을사용하면안되는경우나방사선투과진단을하면안되는경우에사용될수있다. Takayasu 동맥염은관해를위해약물치료을우선적으로시행한다. 보편적으로처음사용되는약물은부신피질호르몬제이며, 이것으로관해에실패하면 cyclophosphamide, azathioprine, methotraxate 등의항암화학요법을사용할수있다. 관해를얻기위해구아닌뉴클레오타이드합성을저해하는 Mycophenolate mofetil을추가할수도있다 (37). 약물치료로호전되지않거나, 협착, 폐색, 동맥류로허혈성증상이발생하는합병증이일어난경우에는혈관성형술, 스텐트삽입술, 우회로조성술등의수술적치료가필요하게된다 (4,5). 수술시기에대하여 Suzuki등의보고에따르면약물치료후임상증상과 ESR, CRP 등을염증진행의표식자로이용하여만성기에수술하는것을원칙으로삼고있으나, 협심증이나울혈성심부전증이발생 하면병기에관계없이수술하는것을권장하고있다 (14). 수술적치료의적응증이되는경우는심각한고혈압을발생시키는신장혈관성고혈압, 심근경색을일으키는심장동맥의협착이있을때, 일상적인활동을할때발생되는사지파행 (claudication), 대뇌허혈이있거나 3개이상의대뇌혈관협착이있을때, 대동맥역류나 5 cm 이상의흉강또는복부대동맥류가있을때이다 (17-19). 수술적치료에는혈관성형술 ( 풍선확장술, 스텐트삽입술 ) 과우회로조성술등이있다. 저자들은 17명 (85.0%) 에서인조혈관이나자가혈관을이용한우회로조성술을시행하였으며, 5명 (25.0%) 에서혈관성형술을시행했다. Takayasu 동맥염에대해수술적치료를시행한 7개의연구논문들을종합해보았을때, 총 140명의환자중사망한경우는 7명이었고, 협착이다시발생하거나폐색이발생한경우는약 22% 로보고되었다 (15,17,20,38-41). 최근에는풍선확장술이나스텐트삽입술등과같이혈관조영술로진단과치료를할수있는경피적혈관내시술이늘고있다. 이러한경피적혈관내시술은흉강이나복부의큰혈관을노출시켜야할경우발생할수있는이환율 (morbidity) 을낮출수있으며 (42), 시술시간이짧은장점이있다. 그러나주기적경과추

차유선외 :Takayasu 동맥염에대한수술적치료 111 적을통한재시술의빈도가잦고, 이에대한장기간의연구성과보고가아직부족하며, 혈관의생검이불가능하여병변의변화를알기어렵다는단점이있다 (3). 결 증상이있는 Takayasu 동맥염환자에서수술적치료는병변이발생한혈관의부위에따라동반발생한증상이심하여약물치료로효과를기다릴수없는경우나, 허혈성증상이있는경우, 약물치료를시행했음에도증상의호전이없는경우에시행될수있다. 수술적방법에는동맥간우회로조성술, 혈관성형술 ( 풍선확장술, 스텐트삽입술 ) 등이있으며, 저자들이수술적치료에는동맥간우회로조성술이 17건 (85.0%) 으로가장많았다. 수술후치료경과는 1명의사망으로 95.0% 의생존율을보였다. 저자들이시행한 Takayasu 동맥염에대한수술결과는높은생존율을보이고있으며재수술을시행받은역시재수술후높은생존율을보이고있다. 저자들의수술결과와이전연구들을종합해보았을때, Takayasu 동맥염에대한수술적치료는안전하고높은생존율을보인다고할수있다. 론 REFERENCES 1) Nakao K, Ikeda M, Kimata S, Niitani H, Miyahara M, Ishimi Z, et al. Takayasu's arteritis: Clinical report of eighty-four cases and immunologic studies of seven cases. Circulation 1967;35:1141-1155. 2) Lupi-Herrera E, Sanchez-Torres G, Marchushamer J, Mispireta J, Horwitz S, Velaj E. Takayasu's arteritis: Clinical study of 107 cases. Am Heart J 1977;93:94-103. 3) Parra JR, Bruce A. Takayasu s disease. Seminars in Vascular Surgery 2003;16:(3):200-208. 4) Giordano JM. Surgical treatment of Takayasu s disease. Cleve Clin J Med 2002;69(Suppl 2):146-148. 5) Numano F. Takayasu arteritis beyond pulselessness. Intern Med 1999;38:226-232. 6) Suzuki A, Amano J, Tanaka H, Sakamoto T, Sunamori M. Surgical consideration of aortitis involving the aortic root. Am J Cardiol 1977;39:744-750. 7) Sharma BK, Jain S, Suri S, Numano F. Diagnostic criteria for Takayasu arteritis. Int J Cardiol 1996;54 Suppl:S141-7. 8) Sharma BK, Iliskovic NS, Singal PK. Takayasu s arteritis may be underdiagnosed in North America. Can J Cardiol 1995;1: 311-316. 9) Hall S, Barr W, Lie JT, Stanson AW, Kazmier FJ, Hunder GG. Takayasu arteritis. A study of 32 North American patients. Medicine 1985;64:89-99. 10) Numano F. Introductory remarks for this special issue of Takayasu s arteritis. Heart Vessels 1992;7(supple):3-5. 11) Numano F, Okawara M, Inomata H, Kobayashi Y. Takayasu s arteritis. Lancet 2000;356:1023-1025. 12) Numano F, Tsunekazu K. Takayasu arteritis Five doctors in the history of Takayasu arteritis. Int J Cardiol 1996;54 (suppl):s1-s10. 13) Lianga P, Hoffmanb GS. Advances in the medical and surgical treatment of Takayasu arteritis Curr Opin Rheumatol 2005; 17:16-24. 14) Moriwaki R, Noda M, Yajima M. Clinical manifestations of Takayasu arteritis in India and Japan. New classification of angiographic findings. Angiology 1997;48:369-379. 15) Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, et al. Takayasu arteritis. Ann Intern Med 1994; 120:919-929. 16) Miyata, T, Sato O, Koyama H, Shigematsu H, Tada Y. Long-term survival after surgical treatment of patients with Takayasu s arteritis. Circulation 2003;108:1474-1480. 17) Lagneau P, Michel JB, Vuong PN. Surgical treatment of Takayasu s disease. Ann Surg 1987;205:157-166. 18) Robbs JV, Abdool-Carrim AT, Kadwa AM. Arterial reconstruction for non-specific arteritis (Takayasu s disease): medium to long-term results. Eur J Vasc Surg 1994;8:401-407. 19) Cherry KJ Jr, McCullough JL, Hallett JW Jr, Pairolero PC, Gloviczki P. Technical principles of direct innominate artery revascularization: a comparison of endarterectomy and bypass grafts. J Vasc Surg 1989;9:718-723. 20) Weaver FA, Yellin AE. Surgical treatment of Takayasu arteritis. Heart Vessels Suppl 1992;7:154-158. 21) Giordano JM, Leavitt RY, Hoffman G, Fauci AS. Experience with surgical treatment of Takayasu s disease. Surgery 1991; 109:252-258. 22) Tada Y, Sato O, Ohshima A, Miyata T, Shindo S. Surgical treatment of Takayasu arteritis. Heart Vessels Suppl 1992;7: 159-167. 23) Rhodes JM, Cherry KJ Jr, Clark RC, Panneton JM, Bower TC, Gloviczki P, et al. Aortic-origin reconstruction of the great vessels: risk factors of early and late complications. J Vasc Surg 2000;31:260-269. 24) Sharma S, Taneja K, Gupta AK, Rajani M. Morphologic mural changes in the aorta revealed by CT in patients with nonspecific aortoarteritis (Takayasu s arteritis). Am J Roentgenol 1996;167:1321-1325. 25) Gravanis MB. Giant cell arteritis and Takayasu aortitis:morphologic, pathogenetic and etiologic factors. Int J Cardiol 2000;75(Suppl):21-33. 26) Rose AG, Gaton E. Takayasu arteritis: a study of 16 autopsy cases. Arch Pathol Lab Med 1980;104:231-237. 27) Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol 2002;55:481-486. 28) Sharma BK, Jain S, Radotra BD. An autopsy study of Takayasu arteritis in India. Int J Cardiol 1998;66 Suppl:85-90. 29) Numano F. Vasa vasoritis, vasculitis, and atherosclerosis. Int J Cardiol 2000;31(suppl):S1-S8.

112 대한혈관외과학회지 : 제 24 권제 2 호 2008 30) Numano F. Takayasu arteritis, Buerger disease and inflammatory abdominal aortic aneurysms-is there a common pathway in their pathogenesis. Int J Cardiol 1998(suppl);66:S5-S10. 31) Inder SJ, Bobryshev YV, Cherian SM, Lord RS, Masuda K, Yutani C. Accumulation of lymphocytes, dendritic cells, and granulocytes in the aortic wall affected by Takayasu s disease. Angiology 2000;51:565-579. 32)Dal Canto AJ, Virgin HW. Animal models of infectionmediated vasculitis: implications for human disease. Int J Cardiol 2000;75:S37-S45. 33) Fukushima T. Radiological study in Takayasu s arteritis with special reference to angiographic manifestations. Nagasaki Iggakkai Zasshi 1984;59:141-153. 34) Schmidt WA, Nerenheim A, Seipelt E, Poehls C, Gromnica- Ihle E. Diagnosis of early Takayasu arteritis with sonography. Rheumatology 2002;41:496-502. 35) Park JH. Conventional and CT angiographic diagnosis of Takayasu arteritis. Int J Cardiol 1996(suppl);54:S135-S141. 36) Tso E, Flamm SD, White RD, Schvartzman PR, Mascha E, Hoffman GS. Takayasu arteritis: Utility and limitations of magnetic resonance imaging in diagnosis and treatment. Arthritis Rheum 2002;46:1634-1642. 37) Daina E, Schieppati A, Remuzzi G. Mycophenolate mofetil for the treatment of Takayasu arteritis: Report of three cases. Ann Int Med 1999;130:422-426. 38) Liang P, Tan-Ong M, Hoffman GS. Takayasu s arteritis: vascular interventions and outcomes. J Rheumatol 2004;31: 102-106. 39) Weaver FA, Kumar SR, Yellin AE, Anderson S, Hood DB, Rowe VL, et al. Renal revascularization in Takayasu s arteritis-induced renal artery stenosis. J Vasc Surg 2004;39: 749-757. 40) Pajari R, Hekali P, Harjola PT. Treatment of Takayasu s arteritis: an analysis of 29 patients. Thorac Cardiovasc Surg 1986;34:176-181. 41) Teoh MK. Takayasu s arteritis with renovascular hypertension: results of surgical treatment. Cardiovasc Surg 1999;6:626-632. 42) Huẗtl K, Nemes B, Simonffy A, Entz L, Beŕczi V. Angioplasty of the innominate artery in 89 patients: Experience over 19 years. Cardiovasc Intervent Radiol 2002;25:109-114.