Korean J Vasc Endovasc Surg 2013;29(4):142-146 http://dx.doi.org/10.5758/kjves.2013.29.4.142 복부대동맥류의스텐트결합인조혈관시술후발생한파열을동반한지연성 Ib 형속누출 1 예 서울대학교의과대학외과학교실 1, 영상의학교실 2 박대도 1 ㆍ민상일 1 ㆍ제환준 2 ㆍ정진욱 2 ㆍ김서민 2 ㆍ민승기 1 ㆍ하종원 1 Successful Endovascular Treatment of Delayed Type Ib Endoleak with Aortic Rupture after Endovascular Repair of Abdominal Aortic Aneurysm Daedo Park, M.D. 1, Sang-Il Min, M.D. 1, Hwan Jun Jae, M.D. 2, Jin Wook Chung, M.D. 2, Suh Min Kim, M.D. 2, Seung-Kee Min, M.D. 1 and Jongwon Ha, M.D. 1 Departments of Surgery 1 and Radiology 2, Seoul National University College of Medicine, Seoul, Korea Endovascular aneurysm repair (EVAR) has progressively become the preferred method for abdominal aortic aneurysm repair. Controlled studies have indicated that EVAR is related to decreased perioperative morbidity and mortality compared with open repair. However, long-term complications are more common. The most common complication following EVAR is an endoleak. Few studies on delayed type Ib endoleak with aortic rupture have been found in the literature. We report a case of a 92-year-old man with a delayed type Ib endoleak with aortic rupture that developed 7 years after EVAR. Lifelong surveillance after EVAR is mandatory. Key Words: Endovascular aneurysm repair, Type Ib endoleak, Abdominal aortic aneurysm, Rupture 중심단어 : 혈관내동맥류재건술, Ib 형속누출, 복부대동맥류, 파열 서 혈관내동맥류재건술 (endovascular aneurysm repair, EVAR) 은 1991년 Parodi 등 (1) 이처음보고한이래로덜침습적이고, 개복수술 (open aneurysm repair) 에비해시술이용이하며, 시술후빠른회복등의장점을이유로복부대동맥류개복수술의대안으로제시되어왔다 (2). 그리고지난 20여년동안점차경험이증가하고장비가발달하면서국외및국내에서 EVAR 시술이급속히확대되는양상을보이고있다 (3,4). 하지만이러한발전에도 접수일 : 2013년 9월 21일, 수정일 : 2013년 10월 22일, 승인일 : 2013년 11월 4일책임저자 : 민상일, 서울시종로구대학로 101 우 110-774, 서울대학교의과대학서울대학교병원외과 Tel: 02-2072-2330, Fax: 02-766-3975 E-mail: surgeonmsi@gmail.com 론 불구하고아직까지스텐트이동, 파열, 꺾임, 속누출 (endoleak) 등의합병증이존재하며 (5), 특히 1형과 3형의속누출은동맥류파열을동반할수있기때문에더욱적극적인치료를요한다 (6). 저자들은복부대동맥류의 EVAR 시술후 7년째에발생한파열을동반한지연성 Ib형속누출을경험하였고, 이를경피적혈관내스텐트삽입을통해효과적으로치료하였기에보고하고자한다. 증례 92세남자환자가 2일전부터발생한복통과구토를주소로타병원응급실을내원하였다. 복부전산화단층촬영에서복부대동맥내에위치한스텐트결합인조혈관의속누출을동반한복부대동맥류파열소견을보여서울대학교병원으로전원되었다. 환자는과거력상 7년전 5.7 cm 크기의복부대동맥류로 Zenith aortic stent graft (Cook Medical, Bloomington, IN, USA) 를사용하여 EVAR 142
Daedo Park, et al: Delayed Type Ib Endoleak 143 Fig. 2. Computed tomography image shows rupture of the aneurysmal sac and retroperitoneal hematoma (arrow). Fig. 1. Angiographic images of previous endovascular aneurysm repair. (A) Angiography shows infrarenal abdominal aortic aneurysm. (B) Completion angiography. 시술을받은병력이있었다 (Fig. 1). 이후특별한특별한증상이없어환자자의로혈관외과외래방문을중단하였으나, 고혈압, 협심증, 만성신부전으로주 3회혈액투석을받으며심장내과와신장내과외래에서정기적인추적관찰중이었다. 하지만 EVAR 후 7년동안복부전산화단층촬영은시행하지않았다. 타병원내원당시활력징후는안정적이었으나 hemoglobin (Hb) 7.1 mg/dl( 정상범위, 13 17 mg/dl) 로혈색소수치의저하소견을보여농축적혈구 1단위를수혈받은후전원되었다. 신체검진소견상복부는부드러웠으나좌하복부와좌상복부에압통이있었다. 서울대학교병원내원직후시행한혈액검사에서는 Hb 9.2 mg/dl, platelet 55,000( 정상범위, 130,000 400,000/μL), blood urea nitrogen 15 mg/dl( 정상범위, 10 26 mg/dl), creatinine 4.45 mg/dl( 정상범위, 0.7 1.4 mg/dl) 소견을보였다. 복부전산화단층촬영소견상좌측엉덩동맥과스텐트말단부착부위에속누출이있었고복부대동맥류는 7.5 cm 크기로좌측후방부위의파열을동반하여좌측후복강내로혈종을형성하고있었다 (Fig. 2). 환자가고령이고, 고혈압, 협심증의병력이있으며, 환자의혈역학적활력징후가안정적이었기때문에개복수술보다는혈관내치료로인조혈관결합스텐트를추가삽입하기로계획하였다. 복부대동맥류파열이동반되어있어응급으로전신마취하에시술하였다. 먼저우측넙다리동맥천자후 5Fr 도관집 (sheath) 을통하여 Davis catheter와 Terumo guidewire를삽입하고삽입되어있는스텐트의가장근위부까지진입해, scaled pigtail catheter로교체후골반혈관을조영하여좌측스텐트부착부위의속누출을확인하였다. 좌측넙다리동맥을박리하고 7Fr 도관집 을삽입하고 Lunderquist guidewire를통해스텐트도관집을삽입하였다. 이를통해 16 12 12 cm 크기의 Gore Excluder AAA Endoprosthesis iliac extender (WL Gore & Associates, Inc., Flagstaff, AZ, USA) 를삽입후 8 mm와 12 mm의풍선으로몰딩하였다 (Fig. 3). 시술종료직전시행한혈관조영술에서속누출이없는것을확인하고시술을마쳤다 (Fig. 4). 시술시간은 95분이었고, 시술중농축적혈구 1.5단위, 혈소판농축액 12단위가투여되었으며, 활력징후는안정적이었다. 환자는시술후 4일째특별한합병증이없는상태로퇴원하였고, 현재 6개월째특별한합병증없이외래추적관찰중이다. 고찰복부대동맥류의치료로 EVAR는개복수술과비교할때장기적인생존율은비슷하면서시술이쉽고덜침습적이며회복이빠른장점을가지고있어최근들어선호되고있는추세이다 (7). 하지만 EVAR는속누출, 스텐트이동, 꺾임등의스텐트관련합병증으로인해이차적중재시술이나재수술이필요한경우가생기는단점이있다 (5). EVAR 시술후발생하는합병증중속누출이가장흔하며, EVAR를시행받은환자 4명중 1명은추적관찰기간중속누출을경험한다고알려져있다 (8). Chang 등 (9) 은 EVAR를시행받은 1,736명의환자에서평균 3년의추적관찰기간동안 3.5% 에서 1형속누출, 27.2% 에서 2형속누출, 0.9% 에서 3형속누출이발생했다고보고하였다. 그리고 Mehta 등 (10) 은 EVAR를시행받은 1,768명의환자에서평균 34개월의추적관찰기간동안 19.2% 의환자가 2차적시술이필요했으며, 2차적시술의원인으로 15% 의 1형속누출, 40.1% 의 2형속누출, 1.5% 의 3형속누출을보고하였다. 속누출은발생시기에따라일차 ( 30일) 와이차 (>30
144 Korean J Vasc Endovasc Surg Vol. 29, No. 4, 2013 Fig. 3. Angiographic images of (A) type Ib endoleak (arrow) and (B) 12 mm molding balloon. Fig. 4. Completion angiography shows patent bilateral iliac flow without residual endoleak. 일 ) 로나뉘고, 발생위치에따라스텐트말단으로부터혈류가동맥류내로흘러들어오는경우를 1형, 허리동맥, 하장간막동맥등으로부터혈류가동맥류내로들어오는경우를 2형, 이식편이찢어지거나분리되어혈류가동맥류내로들어오는경우를 3형, 시술 30일내에혈류가이식편으로부터스며나오는것을 4형으로분류한다 (11). 특히 1형과 3형속누출은해마다 1% 가량의복부대동맥류의파열위험을가지며, 나중에개복수술을하게되는위험도매해 2% 가량증가하기때문에발견즉시치료 를요한다 (12). 속누출의원인으로동맥류의해부학적형태, 동맥류의꺾임정도, 크기, 스텐트종류, 대동맥의리모델링등여러가지가제시되고있다 (13). 그중에서도 Ib형속누출의원인으로짧은온엉덩동맥길이, 온엉덩동맥의심한꺾임, 스텐트의근위부로의이동, 부착부위동맥의석회화등이제시되고있다 (14). 일반적으로 Ib형속누출은말단부위의추가스텐트삽입으로치료하며, 지속적인속누출이있을경우환자가개복이가능한상태라면개복수술을권장하고있다 (8). 지연성 Ib형속누출에관한증례로외국은 Faccenna 등 (15) 이 EVAR 시행 8년후에발생한 Ib형과 3형의복합속누출을추가스텐트삽입으로치료하였다는보고가있고, 국내는 Park 등 (16) 이 EVAR 시행 5년후발생한 Ib형의속누출을마찬가지로추가스텐트삽입을통해치료했다는보고가있다. 저자들역시 EVAR 시행 7년후발생한지연성속누출을추가스텐트삽입을통해성공적으로치료할수있었다. 이와같은 EVAR 시행후시간이지나발생한 1형속누출은발생빈도가낮아간과하기쉬운합병증이지만치명적인결과를초래할수있으므로정기적인검사를통해조기발견을위해노력해야한다. EVAR 시행시원위부를바깥엉덩동맥까지연장시킨경우속엉덩동맥에서 2형속누출이발생할수있고이를예방하기위해속엉덩동맥을폐쇄하는시술이요구되기도한다. 하지만속엉덩동맥색전술후둔부괴사, 하지신경장애, 장허혈, 성기능장애, 둔부파행등의골반허혈증상을유발시킬수있으므로주의를요한다 (17). 이환자의경우 7년전 EVAR 시행당시우측속엉덩동맥
Daedo Park, et al: Delayed Type Ib Endoleak 145 까지동맥류가확장되고바깥엉덩동맥의협착을동반하여시술과정에서우측속엉덩동맥의입구가폐쇄되었다. 하지만시술후 7년동안골반허혈증상이없었고, 곁순환이발달된상태를확인하고, 지연성 Ib형속누출을치료하기위해추가스텐트를삽입하면서좌측속엉덩동맥의입구를폐쇄할수있었다. 하지만고령의복부대동맥류환자는곁순환이비교적적게발달되므로시술및시술후경과관찰에각별한주의가필요하다. EVAR 시행후에는 1, 6, 12개월에복부전산화단층촬영을시행하고, 그후매년복부전산화단층촬영을시행하며평생추적관찰하는것이권장되고있다 (8). 하지만 EVAR 시행후추적관찰이안되는환자가 8.1 65% 에이르는것으로보고되고있으며 (10,18), 이증례의환자역시 7년동안심장내과와신장내과추적관찰은하고있었으나영상검사를전혀하지않고있었기에복부대동맥류의추적관찰은이루어지지않은상태였다. Mehta 등 (19) 은 EVAR 후발생한지연성파열이평균 29개월의추적관찰기간동안 1.5% (27/1,768) 에서발생하였으며, 가장많은원인으로환자가병원에오지않은경우 (follow-up loss, 74%) 라고보고하였다. 또한 EVAR 시술후정기적인추적관찰을하지않은환자들이정기적인추적관찰을한환자들보다파열이나동맥류확장등의치명적인합병증발생률이더높은것으로보고되고있다 (20). 따라서 EVAR 시술후에는평생동안의정기적인추적관찰이필요하고, 시술전환자및보호자들에게충분히그필요성을설득하여야한다. 또한 EVAR 시술을하는의사는환자의장기추적관찰을늘릴수있는방안을모색하여야하겠다. REFERENCES 1) Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499. 2) De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881-1889. 3) Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective. J Vasc Surg 2008;47:1165-1170. 4) Park YJ, Kim N, Kim YW. Investigation of current trend of AAA treatment in Korea. J Korean Surg Soc 2011;80: 125-130. 5) Van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2002;35:461-473. 6) Powell A, Benenati JF, Becker GJ, Katzen BT, Zemel G, Tummala S. Postoperative management: type I and III endoleaks. Tech Vasc Interv Radiol 2001;4:227-231. 7) Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364:843-848. 8) Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009;50(4 Suppl):S2-S49. 9) Chang RW, Goodney P, Tucker LY, Okuhn S, Hua H, Rhoades A, et al. Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry. J Vasc Surg 2013;58:324-332. 10) Mehta M, Sternbach Y, Taggert JB, Kreienberg PB, Roddy SP, Paty PS, et al. Long-term outcomes of secondary procedures after endovascular aneurysm repair. J Vasc Surg 2010; 52:1442-1449. 11) Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35:1048-1060. 12) Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, Laheij RJ. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 2000;32:739-749. 13) Sampaio SM, Shin SH, Panneton JM, Andrews JC, Bower TC, Cherry KJ, et al. Intraoperative endoleak during EVAR: frequency, nature, and significance. Vasc Endovascular Surg 2009;43:352-359. 14) Albertini JN, Favre JP, Bouziane Z, Haase C, Nourrissat G, Barral X. Aneurysmal extension to the iliac bifurcation increases the risk of complications and secondary procedures after endovascular repair of abdominal aortic aneurysms. Ann Vasc Surg 2010;24:663-669. 15) Faccenna F, Bresadola L, Alunno A, Gattuso R. Type IB and type III endoleak 8 years after endovascular aneurysm repair. J Vasc Surg 2012;55:848. 16) Park EJ, Kim HT, Cho WH, Kim YH. Type I endoleak five year after endovascular repair of abdominal aortic aneurysm. Korean J Vasc Endovasc Surg 2011;27:76-79. 17) Lee JH, Kim HJ, Choi SK, Shin WY, Kim JY, Hong KC, et al. Effectiveness of embolization of internal iliac artery during endovascular aneurysm repair. Korean J Vasc Endovasc Surg 2011;27:151-155. 18) Kret MR, Azarbal AF, Mitchell EL, Liem TK, Landry GJ, Moneta GL. Compliance with long-term surveillance recommendations following endovascular aneurysm repair or type B
146 Korean J Vasc Endovasc Surg Vol. 29, No. 4, 2013 aortic dissection. J Vasc Surg 2013;58:25-31. 19) Mehta M, Paty PS, Roddy SP, Taggert JB, Sternbach Y, Kreienberg PB, et al. Treatment options for delayed AAA rupture following endovascular repair. J Vasc Surg 2011;53: 14-20. 20) Jones WB, Taylor SM, Kalbaugh CA, Joels CS, Blackhurst DW, Langan EM 3rd, et al. Lost to follow-up: a potential under-appreciated limitation of endovascular aneurysm repair. J Vasc Surg 2007;46:434-440.