대한내과학회지 : 제 88 권제 3 호 2015 http://dx.doi.org/10.3904/kjm.2015.88.3.303 하대정맥필터내혈전의관상동맥와이어를이용한기계적제거술 1예 부산보훈병원 1 내과, 2 심혈관센터 박종익 1 김수홍 2 손창배 2 이시원 2 오송희 1 정민웅 1 박세령 1 Mechanical Thrombectomy by the Rolling Technique Using a Coronary Wire in a Patient with Recurrent Inferior Vena Cava Filter Thrombosis Jong Ik Park 1, Su Hong Kim 2, Chang-ae Sohn 2, Sea-Won Lee 2, Song Hee Oh 1, Min-Woong Jeong 1, and Se-Ryeong Park 1 1 Department of Internal Medicine and 2 Cardiovascular Center, usan Veterans Hospital, usan, Korea permanent inferior vena cava (IVC) filter with anti-coagulation therapy may be considered in patients with recurrent pulmonary embolism. IVC filter thrombosis is a challenging clinical problem. Here, we report our experience in treating one such patient using mechanical thrombectomy via the rolling technique with a 0.014-inch coronary wire. (Korean J Med 2015;88:303-307) Keywords: Vena cava filters; Thrombosis; Thrombectomy 서론하대정맥필터는 1960년대에처음사용하기시작한후심각한혈역학적인혈관폐쇄를예방하기위해서사용되어왔다. 그러나필터삽입후에도발생하는재발성심부정맥혈전증에대해서는항응고치료가지속되어야한다. 저자들은제2형 S단백유전자결핍에의한재발성심부정맥혈전증에대한치료로하대정맥필터를삽입하고항응고치료를지속하고있는환자에서발생한하대정맥필터혈전증 을경험하고 0.014인치관상동맥와이어를이용하여기계적혈전제거술을시행하고치료했기에보고하는바이다. 증례환자 : 64세남자주소 : 양하지함요부종, 통증현병력 : 64세남자환자는 2주간지속되는양쪽다리의함요부종으로내원했다. 과거력상환자는 2010년 4월에본원 Received: 2014. 6. 10 Revised: 2014. 7. 23 ccepted: 2014. 8. 26 Correspondence to Su Hong Kim, M.D., Ph.D. Division of Cardiology, Department of Internal Medicine, usan Veterans Hospital, 420 aegyang-daero, Sasang-gu, usan, 617-717, Korea Tel: +82-51-601-6741, Fax: +82-51-601-6745, E-mail: dhugie@naver.com Copyright c 2015 The Korean ssociation of Internal Medicine This is an Open ccess article distributed under the terms of the Creative Commons ttribution - 303 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- The Korean Journal of Medicine: Vol. 88, No. 3, 2015 - 에서급성폐동맥색전증및제2형 S단백결핍증으로진단받고비타민 K 길항제를 6개월간사용후항혈소판제제로대체하여지속했다. 그러나 2011년 9월페동맥색전증이재발하여하대정맥필터삽입술을시행했고이후하대정맥필터혈전증이발생하여본원에서돼지꼬리모양도관 (pig-tail 카테터 ) 을이용한중재적시술을시행하였다. 시술이후외래경과관찰도중 2013년 8월 2주전부터시작된양하지부종으로본원응급실로내원하였다. 검사실소견 : 말초혈액검사에서 D-dimer 20 µg/ml, 프로 트롬빈시간 (prothrombin time, PT) 15.0초 (international normalized ratio, INR 1.20), 활성화부분트롬보플라스틴시간 (activated partial thromboplastin time) 31.8초, 백혈구 8,610/mm 3, 헤모글로빈 12.1 g/dl, 혈소판 162,000/mm 3, 요소질소 23 mg/ dl, 크레아티닌 1.0 mg/dl였다. 방사선소견 : 응급실에서시행한복부및하지혈관컴퓨터단층촬영상하대정맥필터부터양쪽오금정맥까지관찰되는대량의혈전이발견되었다 (Fig. 1). 치료및경과 : 치료를위해경구항응고제는저분자량헤파 Figure 1. Massive thrombosis pattern at pre- and post-management on computed tomography (CT) venography. () bdominal CT venography before thrombectomy revealed a massive recurrent thrombosis from the inferior vena cava filter to the popliteal vein (white arrows). () fter mechanical thrombectomy and anti-coagulation therapy, near-complete clearance of the thrombosis was achieved (white arrows). Figure 2. Massive thrombosis was improved after thrombectomy venography. () Venography before thrombectomy revealed thrombosis of the inferior vena cava filter and inferior vena cava. () Venography after thrombectomy demonstrated successful removal of a large part of the thrombosis. - 304 -
- Jong Ik Park, et al. Thrombectomy in IVC filter - Figure 3. () The modified coronary wire at procedure field. () The modified coronary wire used in the guriguri-kun method (one of the rolling technique s name). Figure 4. spirated thrombosis. 린 (enoxaparin sodium; 1 mg/kg, 1일 2회 clexan [Sanofi-ventis, Maison lfort, France]) 으로바꿔서피하투여했고심한함요부종과하지통증을호소하여중재시술을통한혈전제거술을시행하기로했다. 환자의우측대퇴정맥을통해 5 Fr 혈관유도초를삽입했고혈관조영술상하대정맥필터에서부터시작되어양쪽총장골정맥까지발생된다량의혈전을확인했다 (Fig. 2). 먼저돼지꼬리모양도관을이용한회전술기를시도했으나큰효과를보지못했다. 이에저자들은시술장내에서 0.014인치관상동맥와이어를마름모모양으 로변형시켜드릴형태로만든후에 (Fig. 3) 회전술기를시도하였다 (guriguri-kun technique). 수차례와이어를통해혈전을보다작은조각들로파괴한후 7 Fr 유도초로바꾸고 Judkin s right 4 (JR4) 유도카테터를이용하여혈전을수차례흡인하여제거했다 (Fig. 4). 최종혈관조영술상총장골정맥내의혈전은소실되었고하대정맥필터내부에일부혈전이남아있는것을확인하였으며저분자량헤파린을사용하여경구항응고제치료를병행하기로하고시술을종료했다 (Fig. 2). 기계적혈전제거술이후남아있는혈전을제거하기위해저분자량헤파린을이용한비경구항응고요법을지속했고시술 7일째양하지부종의감소와통증감소를확인하였다. 시술 17일째시행한복부및하지혈관컴퓨터단층촬영에서하대정맥필터부터양쪽오금정맥까지관찰되는혈전이대부분감소된것을확인했고 (Fig. 1) 저분자량헤파린피하내주사를와파린 5 mg으로교체후프로트롬빈시간 (PT) 23.9초 (INR 2.2) 로확인된후에외래에서추적관찰하기로하고퇴원했다. 퇴원 1개월후에외래에서시행한프로트롬빈시간 (PT) INR은 3.6이었고호흡곤란등의폐색전증을의심할만한증상은보이지않았으며복부및하지혈관컴퓨터단층촬영에서도하대정맥필터내에 - 305 -
- 대한내과학회지 : 제 88 권제 3 호통권제 655 호 2015 - Figure 5. Follow up computed tomography finding (abdomen and chest). () fter 1 month, abdominal computed tomography venography indicated no recurrent thrombosis at the inferior vena cava filter. () No evidence of a pulmonary embolism was observed. 재발소견이나폐색전증을의심할만한소견이관찰되지않음을확인했다 (Fig. 5). 이후환자는현재까지추가재발없이경구항응고치료를지속하고있다. 고찰하대정맥필터삽입술은항응고치료에반응이적은반복적인폐동맥혈전증을예방하기위해서 1960년대후반부터현재까지사용되어져왔다 [1]. 하대정맥필터혈전증은 7.7% 의확률로발생하는흔하지않은합병증이지만지속적인항응고요법을시행하지않으면 15.3% 까지발생률이증가한다 [2]. 하대정맥필터혈전증의치료로는경구용항응고요법, 정맥용항응고요법, 수술적혈전제거술, 카테터를이용한직접적혈전용해요법그리고경피하기계적혈전제거술이있다. 하대정맥필터를삽입함으로써주요장기의혈전으로인한문제는예방할수있으나필터내의혈전증에대해서는명확한치료지침이없는상태로정맥혈전색전증에대한치료방침대로경구항응고요법을지속하고있다 [3,4]. 이와함께심한부종과하지통증을동반한심부정맥혈전증이있는경우 merican College of Chest Physicians (CCP) 치료지침 (9판) 에따라장대퇴골심부정맥혈전증, 증상발현 7일이내, 좋은기능적상태, 1년이상의기대수명, 적절한장비와숙련된의사의다섯가지요건이충족되는경우외과적혈전제거술, 혈전용해술또는경피적기계적혈전제거술 이고려될수도있다 [5]. Plate 등 [6] 의연구에따르면급성장대퇴골심부정맥혈전증환자에서항응고요법치료와함께혈전제거술을시행한경우항응고요법을단독으로사용한환자보다장기간의하지치료결과 (limb outcome) 가좋다는결과를보고한바있다. 일반적으로경피하기계적혈전제거술은흡입카테터를이용하여매뉴얼로흡입하는방법과흡입전용장치를사용하는방법이있다. 흡입카테터를통한매뉴얼흡인이많이사용되고있으나본증례와같이다량의혈전인경우카테터가혈전으로막혀버리는경우가흔하고시술도중에도추가적으로발생하는혈전으로인해시술에어려움이따른다. 또한본증례와는달리하대정맥필터가삽입되어있지않은상태에서하지정맥에발생된혈전을흡입하다이차적으로더욱치명적인폐동맥혈전증을유발시킬수도있으며매뉴얼흡입만으로모든혈전들을다제거하기엔많은시간과노력이필요하다. 이에대한대안으로다양한방식의흡입전용장치를사용할수도있는데회전력을이용해혈전을파괴하는장비 (rotational devices; mplats Thrombectomy device, Straub Rotarex, Tretorola device, Trellis device) 등은혈관내피손상을유발시킬수있고흐름용해를이용한장비 (rheolytic device; ngiojet device) 는고압식염수제트를이용해혈전을파괴, 흡입하는방식으로혈관내손상을감소시킬수있으나고압제트로인한용혈이발생하여아데노신, 칼륨의분비로 - 306 -
- 박종익외 6 인. 하대정맥필터내혈전제거술 1 예 - 서맥과혈뇨, 드물게이차성췌장염과신부전이발생할수있는단점이있다 [7]. 초음파를이용한장비 (ultrasound-enhanced devices; EKOS endowave, Omniwave) 는혈관내피손상이나용혈이없는장점이있으나용해시간이길어지는단점이있다 [7]. 이러한흡입전용장치가보다안전하고효율적으로혈전을제거할수있지만장비사용에대한비용증가와흡입방식에따른장단점은고려되어야할사항이다. 저자들은 0.014인치관상동맥와이어를변형하여드릴모양으로만든후혈전내부에서회전시킴으로써혈전을보다더작은조각으로나누어지도록하여흡인이더욱용이하도록했다. 이는저자들뿐만아니라일본의몇몇시술자들도전용흡입장치대신사용하는술기이다. 0.014인치관상동맥시술용와이어는가늘어변형시키기가용이하고회전력도잘전달되어사용하기편리한장점이있다. 현재기계적으로혈전을분해하는방법이보편적으로사용되는것은아니다. 그러나흡인전용장치가없는상황에서매뉴얼흡인만으로다량의혈전을시술로써제거해야하는경우에단순흡입보다는위와같은보다다양한방법들을추가적으로함께사용한다면성공적인시술결과를얻을수있을것이다. 저자들은다량의하대정맥필터혈전증에대해 0.014인치와이어를사용한회전기술을통해보다용이하게혈전을제거할수있었기에증례보고하는바이다. 요약하대정맥필터삽입술을시행받은환자에서필터내혈전증은드물지만발생할수있다. 저자등은양하지함요부종및통증을주소로내원한환자의대량의혈전을 0.014 인치관상동맥와이어를변형한도구를이용해경피하기계적혈전제거술을시행했기에이를보고하는바이다. 중심단어 : 하대정맥필터 ; 혈전 ; 기계적혈전제거술 REFERENCES 1. Greenfield LJ, Michna. Twelve-year clinical experience with the Greenfield vena caval filter. Surgery 1988;104:706-712. 2. ecker DM, Philbrick JT, Selby J. Inferior vena cava filters. Indications, safety, effectiveness. rch Intern Med 1992;152:1985-1994. 3. Kearon C, Kahn SR, gnelli G, et al. ntithrombotic therapy for venous thromboembolic disease: merican College of Chest Physicians Evidence-ased Clinical Practice Guidelines (8th edition). Chest 2008;133(6 Suppl):454S-545S. 4. Hirsh J, ates SM. Clinical trials that have influenced the treatment of venous thromboembolism: a historical perspective. nn Intern Med 2001;134:409-417. 5. Kearon C, kl E, Comerota J, et al. ntithrombotic therapy for VTE disease: antithrombotic therapy and prevention of Thrombosis, 9th ed: merican College of Chest Physicians Evidence-ased Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S-e494S. 6. Plate G, Eklöf, Norgren L, Ohlin P, Dahlström J. Venous thrombectomy for iliofemoral vein thrombosis-10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg 1997;14:367 374. 7. Karthikesalingam, Young EL, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ. systematic review of percutaneous mechanical thrombectomy in the treatment of deep venous thrombosis. Eur J Vasc Endovasc Surg 2011;41:554-565. - 307 -