대한내과학회지 : 제 83 권제 6 호 2012 http://dx.doi.org/10.3904/kjm.2012.83.6.786 잘못된 Stent 삽입치료후슬와동맥포착증후군에서발생한슬와동맥의완전폐쇄 1예 연세대학교의과대학 1 내과학교실, 2 심장혈관병원심장내과, 3 심장혈관외과학교실, 4 영상의학과학교실 김은혜 1 이인선 1 김승환 2 신상훈 2 이택연 3 이도연 4 최동훈 2 Total Popliteal Artery Occlusion after Stent Insertion Diagnosed as Popliteal Artery Entrapment Syndrome Eun Hye Kim 1, In-Sun Lee 1, Seong-Hwan Kim 2, Sang-Hun Shin 2, Taek-Yeon Lee 3, Do-Yun Lee 4, and Donghoon Choi 2 1 Department of Internal Medicine, 2 Divison of Cardiology, Yonsei Cardiovascular Center, 3 Department of Cardiovascular Surgery, and 4 Department of Radiology, Yonsei University College of Medicine, Seoul, Korea Entrapment of the popliteal artery is a rare cause of ischemia of the lower extremities in young males. The development of local occlusive or aneurysmal changes of the popliteal artery is caused by abnormal anatomical relationships between vascular and musculotendinous structures in the popliteal fossa. A 55-year-old male patient visited Yonsei University College of Medicine with the chief complaint of claudication in his right calf. He had undergone stent insertion in the right popliteal artery for peripheral artery occlusive disease 2 years earlier. Lower extremity CT angiography showed stent fracture and in-stent thrombosis. He underwent femoral-to-popliteal artery bypass surgery. Postoperative lower extremity CT angiography showed that the vein graft was compressed between the medial head of the gastrocnemius and the semimembranosus muscle. However, the blood flow was normal and his pain was relieved. (Korean J Med 2012;83:786-790) Keywords: Entrapment syndrome; Popliteal artery; Bypass surgery 서론슬와동맥포착증후군은드물지만적절한치료를하지않을경우사지를잃을수도있는말초혈관질환으로주로젊은성인에호발되는것으로보고되고있다. 또한흔하지않은임상적진단으로슬와동맥에인접한근육과건등의 구조물에의해압박되어발생되는것으로외적인동맥의압박은만성적인미세혈관손상, 원위부경색을야기하는초기동맥경화및혈전증등을일으켜조기에치료하지않을경우사지절단과같은심각한합병증을야기할수있다. 저자들은간헐적인우측하지의파행과동통이있었던 55세환자에게서잘못된스텐트삽입술치료후발생한스텐트 Received: 2011. 9. 13 Revised: 2012. 1. 12 Accepted: 2012. 3. 26 Correspondence to Donghoon Choi, M.D., Ph.D. Department of Cardiology, Yonsei University College of Medicine, 50 Yeonsei-ro, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-8530, Fax: +82-2-2227-7732, E-mail: cdhlyj@yuhs.ac Copyright c 2012 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 786 - 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.
- Eun Hye Kim, et al. A case of entrapment syndrome - 골절, 슬와동맥의완전폐쇄를복재정맥 (saphenous vein) 을이용한혈관우회술로치료한 1예를보고하고자한다. 증례환자 : 55세남자주소 : 내원 15일전부터시작된움직이면발생하는오른쪽종아리의통증현병력 : 환자는 2009년말초동맥폐쇄성질환 (peripheral artery occlusive disease) 으로우측슬와동맥에스텐트삽입술을시행받았다. 내원 15일전부터오른쪽발목을움직이거나 30 m 정도를걸으면발생하는오른쪽종아리통증으로타병원에내원하여시행한컴퓨터단층혈관조영술에서이전에삽입한스텐트골절과스텐트내강의완전폐쇄소견이관찰되었다. 이에환자는정밀한검사를원해입원하였다. 가족력 : 특이사항없음. 진찰소견 : 이학적검사에서활력징후는혈압 100/70 mmhg, 맥박수 60회 / 분, 호흡수 14회 / 분, 체온 36.4 로측정되었다. 우측발목맥박이촉지되지않았으며혈압도재어지지않았다. 오른쪽다리의운동범위는정상이었으나, 걷거나오른쪽발목을움직이면오른쪽종아리의통증호소하였다. 검사소견 : 입원당시말초혈액검사에서백혈구 13,020/mm 3, 혈색소 13.5 g/dl, 헤마토크리트 40.3%, 혈소판 230,000/mm 3 이었다. 혈청생화학검사에서 BUN/creatinine 22.0/0.85 mg/dl, Na/K/Cl 140/4.9/102 meq/l였고, 혈당 98 mg/dl, AST/ALT 79/161 IU/L, protein/albumin 7.2/4.2 g/dl, Ca/P 9.7/4.9 mg/dl, cholesterol/ TG/HDL/LDL 209/153/83/99 mg/dl였다. 흉부단순촬영및심전도검사상이상소견없었다. 치료및경과 : 말초혈류검사 (PVR) 를시행하였고우측무릎아래로 0.86으로좌측의 1.27에비해혈류감소한소견을보였다. 컴퓨터단층혈관조영술 (Fig. 1A, 1B) 을시행하였고이전우측슬와동맥에삽입한스텐트골절소견이보였으며우측슬와동맥에저음영의결손으로인한폐쇄가있었다. 또한슬와동맥이비복근의내측두내측으로편위되어있었으며이는슬와동맥포착증후군제1형을시사하는소견이었다 (Fig. 1A and 1B). 내원 2일째혈관조영술 (peripheral angiography) 을시행하였고 (Fig. 2) 이전에삽입한스텐트골절에의한우측슬와동맥의완전폐쇄상태가보였다. 이에혈관재건을위한수술을계획하고내원 3일째수술을시행 Figure 2. Peripheral angiography shows total occlusion of the right popliteal artery and slow distal flow in collateral vessels. A B Figure 1. (A) Lower extremity CT angiography shows stent fracture and total occlusion of the right popliteal artery. (B) Lower extremity CT shows that the right popliteal artery (arrow) is deviated medially and totally occluded. - 787 -
- 대한내과학회지 : 제 83 권제 6 호통권제 628 호 2012 - A B Figure 3. (A) Lower extremity CT shows stent fracture. (B) Lower extremity CT shows stent fracture (circle) and compressed saphenous vein graft (arrow) between the medial head of the right gastrocnemius muscle and the semimembranosus muscle. 고 찰 Figure 4. Postoperative peripheral angiography shows normal blood flow at the saphenous vein graft. 하였다. 우측대퇴부에피부절개를하고박리를진행하였고약 10 cm 정도의우측복재정맥이식편준비를하여우측무릎위아래에서스텐트골절부분및완전폐쇄된동맥의우회로술을시행하였다. 혈전예방을위하여수술당일부터 3일동안헤파린투여하였으며이후에는 aspirin 100 mg, coumadin 5 mg을경구투여하였다. 수술후 6일째퇴원하였으며, 컴퓨터단층혈관조영술 (Fig. 3A, 3B) 에서복재정맥이식부분이비복근내측두와반건양근사이에서눌리는소견을보였다. 그러나혈류는유지되고있었으며이식편내에혈전은보이지않았다. 혈관조영술 (peripheral angiography) (Fig. 4) 에서도이식편에서의혈류가유지되고있는것을관찰할수있었다. 말초혈류검사 (PVR) 를시행하였고오른쪽무릎부분으로 1.28 측정되어이전보다호전된양상을보였다. 수술 2개월이지난현재일상생활에문제없이외래에서경과관찰중이다. 슬와동맥포착증후군은드문질환이지만동맥경화의위험인자가없는젊은성인에서발생하는하지허혈증의한원인이다. 이질환은 1879년의과대학학생이었던 Anderson Stuart에의해해부학적기전이최초로알려졌으며이후 1959년 Hamming 과 Vink 등이포착된슬와동맥의박리를통한수술적요법에의한치료를최초로보고하였다 [1]. 이질환에대한정확한발생빈도는알수없지만 Gibson 등 [2] 은부검예에서 3.5%, Bouhoutsos 와 Daskalakis 등은그리스군에입대한젊은남자에서 0.165% 의유병률을보고하였다. 그러나슬와동맥포착증후군의실질적인유병률은이보다높을것으로추정하고있다. 원인으로는슬와동맥과주변의근육, 건막구조물간의비정상적인해부학적연관관계에의해서슬와동맥이지속적으로압박되어하지혈류장애를초래하는것이다 [3]. 해부학적으로슬와는다이아몬드형태로슬관절후방에서상외측의대퇴이두근, 상내측의반건양근, 하측에는비복근의내, 외측두로이루어진공간이다 [4]. 슬와동맥의정상적인주행경로는내, 외측두의사이를지난다. 슬와동맥은동맥과근육의발생학적과정에서변이로야기된동맥주위의근육및건으로인해포착될수있다. 그러나이러한해부학적이상소견이없으면서혈류장애증상이있는경우무릎관절을신전시키고발목을바닥쪽으로굽히거나배굴 - 788 -
- 김은혜외 6 인. 삽입치료 1 예 - 시키는기능적유발검사에서혈류장애가확인되면기존의슬와동맥포착증후군과구분하여기능성슬와동맥포착증후군이라고하였다 [5,6]. 슬와동맥포착증후군의진단은과거에는혈관조영술로이루어졌으며이것이발견되면추가로자기공명영상을이용하여슬와동맥과주변근육등과의관계를확인하여확진및분류를하였다 [7]. 최근에는삼차원컴퓨터단층혈관조영술을이용하여한번의검사로하지동맥조영및주변의근육등구조물들과의상관관계도알수있고양측하지를동시에검사할수있다 [8]. 슬와동맥포착증후군은해부학적형태에따라네가지로분류된다 [9]. 제1형은비복근의내측두는정상적으로위치하고슬와동맥이비복근의내측두내측으로편위되어있는경우이고, 제2형은슬와동맥은정상적으로위치하고비복근의내측두가정상보다외측에위치하여슬와동맥이이근육의내측으로주행하는경우이고, 제3형은비복근내측두의외측에또하나의부속내측두 (accessory slip) 가슬와동맥을압박하는경우이고, 제4형은슬와근또는섬유띠가슬와동맥을둘러싸는경우이다. 추가적으로상기 4분류중어느한가지형태에더하여슬와정맥도같이압박받는경우를제5형으로, 해부학적이상이없는기능적슬와동맥포착증후군을제6형으로더하여분류하기로한다. 치료원칙은압박의원인이되는근육절제를통한슬와동맥의감압및혈관재건술이다 [10]. 수술방법은동맥이정상인경우근육절제술만으로도충분하나동맥에변성이있거나혈전이있는경우는동맥재건술이필수적이다. 동맥재건술은슬와동맥의손상및변성정도에따라내막절제술또는혈관우회술을적용할수있으나대부분의경우슬와동맥의변성이진행된예가많으므로자가정맥을이용한혈관우회술이가장이상적이다. 해부학적형태및병변의위치에따라내측접근법을선택할수도있으나, 후방접근법이다양한해부학적형태에대한구분을명확히할수있고동맥재건도쉽게할수있어서가장선호되는접근법이다. 본증례에서는근육절제는시행하지못하고스텐트골절부분및완전폐쇄된동맥의우회로술을시행하였다. 그이유는슬와동맥내스텐트가골절되고내강이완전폐쇄된상태로근육절제후슬와동맥절제까지시행하기에는수술의범위가커지고그만큼수술의위험성도커지기때문에혈관우회술만시행하였다. 본증례의경우슬와동맥포착증후군에서잘못된스텐트삽입술치료후발생한스텐트골절과스텐트내강의완전폐쇄가된경우이다. 복재정맥을이용한혈관우회술을시행받았고수술후시행한컴퓨터단층혈관조영술에서이식편이비복근내측두와반건양근사이에서눌리는소견을보였으나이는역동학적압박이며혈류는유지되고있었고이식편내에혈전은보이지않았다. 본증례를통하여슬와동맥포착증후군의치료는스텐트삽입술이아닌혈관우회술등의수술적인치료를고려하여야한다는점을밝히고싶다. 요 슬와동맥포착증후군은드물지만적절한치료를하지않을경우사지를잃을수도있는말초혈관질환으로주로젊은성인에호발되는것으로보고되고있다. 원인으로는슬와동맥과주변의근육, 건막구조물간의비정상적인해부학적연관관계에의해서슬와동맥이지속적으로압박되어하지혈류장애를초래하는것이다. 저자들은간헐적인우측하지의파행과동통이있었던 55세환자에게서잘못된스텐트삽입술치료후발생한스텐트골절, 슬와동맥의완전폐쇄를복재정맥 (saphenous vein) 을이용한혈관우회술로치료한 1예를보고하였다. 슬와동맥포착증후군의치료는스텐트삽입술이아닌혈관우회술등의수술적인치료를고려하여야한다. 약 중심단어 : 슬와동맥포착증후군 ; 우회술 REFERENCES 1. Richard J. Fowl, Richard F. Kempczinski. Popliteal artery entrapment. In: Rutherford RB, ed. Vascular Surgery. 5th ed. Philadelphia: Saunders, 2000:1087-1093. 2. Gibson MH, Mills JG, Johnson GE, Downs AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341-348. 3. Kim DS, Kim SW, Kim BK, Lee HJ, Lee G, Lim CY. Popliteal artery entrapment syndrome: a case report. Korean J Thorac Cardiovasc Surg 2009;42:653-656. 4. Cho SH, Hwang SC, Jeong ST, Cha MS, Sohn KM. Popliteal artery entrapment syndrome: a case report. J Korean Knee Soc 2008;20:97-101. 5. Housseini AM, Maged IM, Abdel-Gawad EA, Hagspiel - 789 -
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