38 HANYANG MEDICAL REVIEWS Vol. 31 No. 1, 2011 기능부전및폐쇄된자가동정맥루인터벤션 Intervention of the Dysfunctional and Thrombosed Autogenous Vascular Access 김용재순천향대학교서울병원영상의학과 Yong Jae Kim, M.D., Ph.D. Department of Radiology, Soon Chun Hyang University, Seoul Hospital, Seoul, Korea 책임저자주소 : 140-743, 서울시용산구한남동 657 번지 순천향대학교서울병원영상의학과 Tel: 02-709-9397, Fax: 02-795-3928 E-mail: intervention.kim@gmail.com 투고일자 : 2010 년 10 월 30 일, 심사일자 : 2010 년 11 월 14 일, 게재확정일자 : 2010 년 12 월 2 일 Abstract In South Korea at the end of 2006, the total number of patients that had undergone renal replacement therapy was 46,730 (hemodialysis: 62.1%, peritoneal dialysis: 17.1%, functioning kidney transplantation: 20.8%). There were 9,197 new renal replacement therapy patients in 2006 and the incidence rate per million 185.3. In South Korea, the most common primary cause of end stage renal disease was diabetic nephropathy (42.3%), hypertensive nephrosclerosis (16.9%), and chronic glomerulonephritis (13.0%). The National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) has recommended placement of autogenous arteriovenous fistulas over alternatives including the use of arteriovenous grafts and central venous catheters to improve the overall outcome of patients undergoing hemodialysis. However, autogenous arteriovenous fistulas, like polytetrafluoroethylene grafts, are also subject to dysfunction and eventual failure. Since first described in 1982, percutaneous transluminal balloon angioplasty has become the mainstay of treatment for accesses failing because of underlying central or peripheral venous stenoses. When angioplasty alone fails, alternative treatment modalities, including stent placement and atherectomy, allow immediate salvage in most cases. Consequently, interventional treatment should be attempted first for dysfunctional and thrombosed autogenous vascular access and should be initiated in all dialysis centers so long as the local radiologists are trained and enthusiastic. Key Words: Autogenous arteriovenous fistula, Dysfunction, Thrombosis, Percutaneous transluminal balloon angioplasty 서론 2006 년현재우리나라신대체요법환자 (renal replacement therapy) 는총 46,730 명 ( 혈액투석 : 62.1%, 복막투석 : 17.1%) 이며, 2006 년새로발생한신대체요법환자는 9,197 명이다. 1 신대체요법의원인으로는당뇨병콩팥병증 42.3%, 고혈압콩팥병증 16.9%, 만성사구체신염 13.0% 등 이다. 1 혈액투석을받는만성신부전환자에서동정맥루의기 능유지는매우중요한문제다. 특히새로발병하는만성신 부전환자는 50 대와 60 대가많고원인질환으로당뇨병콩팥 병증이많은데고령이며여러가지내과적인질환을가진환 자는신장이식수술이나복막투석이적합하지않기때문에혈액투석이필수적이다. 1
Intervention of the dysfunctional and thrombosed autogenous vascular access 39 혈액투석은 1960 년대 Quinton 등이도관을이용한방법 을제시하였고, 2 Brescia 등은말초혈관에서자가피하동정 맥루를만들어투석에이용하였다. 3 그리고 1972 년 Chinitz 등은 bovine graft 를이용한동정맥루를만들었다. 4 The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (DOQI) 에서는상대적으로낮은합병증 과우수한장기개통률에근거해혈액투석을위한영구적혈 관접근수술시인조혈관보다는자가동정맥루를우선적으 로권장하고있다. 5 인조혈관동정맥루보다는우수하지만자 가동정맥루에서도결국엔협착및폐쇄가발생한다. 노동맥 - 노쪽피부정맥동정맥루 (radiocephalic arteriovenous fistula) 에서는문합부위주변 3 cm 이내에, 위팔동맥 - 노쪽 피부정맥동정맥루 (brachiocephalic arteriovenous fistula) 에서는노쪽피부정맥궁 (cephalic arch) 협착이가장많이발생한다. 6, 7 동정맥루의합병증이나폐쇄를줄이기위해적극적인선별검사 (screening test) 와조기경피적치료가중요하다. 8, 9 경피적풍선성형술 (percutaneous angioplasty) 은 1982 년 처음소개되었고, 10, 11 현재는기능부전동정맥루의주된치 료법이되었다. 자근위부를혈압기가압대나손으로압박하여조영제를동맥쪽으로역류시켜확인해야한다. 저자의경험으로는일반적인환자는손으로압박하는것만으로조영제를역류시킬수있으며중심정맥협착으로상지부종이있거나환자가거대한경우혈압기가압대 (blood pressure cuff) 를사용하여조영제를역류시킬수있다 (Fig. 1). 투석접근혈관이미성숙 (immature) 또는깊은곳에위치하여천자하기어려울때나영양동맥 (feeding artery) 에협착이의심된다면위팔동맥 (brachial artery) 를천자하여영양동맥부터유출정맥까지함께검사할수있다. Rajan 등이 94명의노동맥-노쪽피부정맥동정맥루와 57 명의위팔동맥-노쪽피부정맥협착을분석한결과노동맥-노쪽피부정맥동정맥루에서는동정맥문합부 3 cm 이내의노쪽피부정맥 (64%), 팔꿈치아래노쪽피부정맥 (20%) 순으로협착이흔하였으며, 위팔동맥-노쪽피부정맥동정맥루에서는노쪽피부정맥궁 (30%), 노쪽피부정맥유출부 (24%), 동정맥문합부 3 cm 이내의노쪽피부정맥 (22%) 순이었다. 7 본원에서 1997년부터 2006년까지 10년간자가동정맥루협착이의심되시행한샛길조영술 1,624예를분석한결과팔꿈치아래노쪽피부정맥협착 (54%), 중심정맥협착 (15%), 동맥또는동정맥문합부협착 (10%), 팔꿈치위노쪽피부정맥협착 본론 1. 진단적샛길조영술 (Diagnostic Fistulography) DOQI 투석접근혈관지침에서는투석접근혈관의폐쇄를 예방하기위해정기적인검사를하도록유도하고있다. 일주 일에한번씩이학적검사를시행하여투석접근혈관에서맥동 (pulsatility) 이촉지되거나정상적인진음 (thrill) 이느껴지지않았을때샛길조영술을시행하도록권장하고있다. 12 본원에서는일반적으로스칼프베인세트 (BD Korea Inc., Gyeongsangbukdo, Korea) 를사용하여샛길조영술을시 행한다. 진단적샛길조영술시행직후풍선성형술등인터벤 션치료를시행하기위해선바늘천자위치및방향이중요하 다. 정맥유출로협착이의심된다면앞방향 (antegrade) 천자 를, 동정맥문합부주위협착이의심된다면협착근위부에서 역방향 (retrograde) 천자를해야한다. 혈류량이많지않아 천자가어렵다면압박띠 (tourniquet) 로근위부를압박한후 천자를하면된다. 동정맥문합부는흔한협착부위이므로천 Fig. 1. Following suprasystolic inflation of a blood pressure cuff, fistulogram demonstrates reflux across the arteriovenous anastomosis, revealing a short high-grade stenosis (arrow) and radial artery (arrowheads).
40 Hanyang Medical Reviews Vol. 31 No. 1, 2011 (8%) 순이었다 (Fig. 2). 2. 기능부전자가동정맥루의인터벤션치료 1) 시술방법현재는기능부전동정맥루의치료로풍선성형술이매우 Fig. 2. Frequency of stenoses identified at first intervention. 널리사용되고있다. 또한경피적인터벤션의엄격한보고표준 (reporting standard) 도마련되어있다. 13 본원에서는시술전전처치 (premedication) 로 tramadol hydrochloride 50 mg과 chlorpheniramine maleate 2 ml를근육주사한다. 진단적샛길조영술을시행했던바늘주위를베타딘으로소독한후천자주위를리도케인으로국소마취한다. 그후바늘을유도철사를이용하여혈관안내도관집 (vascular introducer sheath) 으로교체한다. 혈관안내도관집은사용될풍선카테터가들어갈수있는최소크기를사용하여혈관손상을최소화한다. 본격적인풍선성형술전에 2,000-5,000 단위의헤파린을투여할수도있지만혈전이없는경우일반적이지않다. 10, 14, 15 노동맥협착이나노동맥문합부주위협착인경우 4 mm 크기의풍선을, 팔꿈치아래노쪽피부정맥협착인경우 5-8 mm 크기의풍선을일반적으로사용한다. 문합부주위협착의풍선성형술시행시동맥의경련 (spasm) 이발생할수있으므로유도철사를동맥에위치시킨후풍선성형술을시행하는것이좋다 (Fig. 3). 풍선확장시간은보통 20-30초정도로하며탄성반동이있거나풍선성형술후혈관의파열 (rupture) 또는박리 (dissection) 가발생한경우 2-3 분까지할수있다. 투석을위한자가동정맥루에서는협착부위에섬유띠 (fibrous band) 가있는경우가있다. 이경우풍선확장압력을 15 atm 이상올리는경우가많아주사기보다 A B C Fig. 3. A 40-year-old man with right radio-cephalic fistula. A) A road-map fistulogram shows radial artery (small arrows), anastomotic site (arrow), and multiple stenoses at the cephalic vein adjacent to arteriovenous anastomosis (arrowheads). B) The stenoses are dilated using a 7mm balloon catheter. Note that the guidewire (arrow) has been left across the radial artery. C) Immediate post-procedural fistulogram shows improvement of the stenosis.
Intervention of the dysfunctional and thrombosed autogenous vascular access 41 는팽창기 (inflator) 를사용하여풍선을확장시켜야한다. 풍 선성형술후에도협착이해결되지않는경우 1) 추가적인유 도철사를협착부위에거치시킨후유도철사와같이풍선성 형술을시행, 2) 1 mm 큰크기의풍선을사용, 3) 절단풍선 (cutting balloon) 을사용, 4) 고압력풍선 (high-pressure balloon) 을사용하여극복할수있다. 풍선성형술시통증이 심할수있는데협착주위를리도케인으로국소마취를하면 통증을경감시킬수있다. 일반적으로풍선성형술후해부학 적성공은잔존협착이 30% 미만인경우이며, 임상적성공은 치료전호소하던증상 ( 비정상적이학적검사, 투석후긴지 혈시간, 투석시천자의어려움등 ) 이해결되었거나치료후 1 회이상정상적인투석을시행받은경우로하고있다. 저자 의경우풍선성형술후잔존협착이 30% 미만이고이학적검 사에서진음 (thrill) 이촉지되면성공적인풍선성형술로간주 한다. 위팔또는아래팔동정맥루기능부전에대한치료로스텐 트설치는극히드물다. 일반적인스텐트설치적응증으로풍 선성형술후정맥파열또는탄성반동 (elastic recoil) 이다. 그 러나투석을위한동정맥루는투석시천자와압박지혈이반 복되므로스텐트설치는피하는것이바람직하다. 2) 결과 기능부전자가동정맥루치료로풍선성형술후개통률은 많은논문들에서보고되었다. 14, 16-18 발표된논문들에서는풍 선성형술후 6 개월비보조개통률 (unassisted patency rates) 를 40-50% 로보고하고있다. 수술적치료후개통률은 주로누적개통률 (cumulative patency) 로보고하여풍선성 형술후개통률과비교하지는어렵지만 1 년비보조개통률이 50% 가되도록권고하고있다. 5 Turmel-Rodrigues 등 19 은 200 예이상의기능부전자가동정맥루를풍선성형술로치료 하였는데아래팔동정맥루의 1 년일차개통률은 50%, 2 년일 차개통률은 37% 로보고하였고, 위팔동정맥루의 1 년일차 개통률은 35%, 2 년일차개통률은 24% 로보고하였다. 위팔 동정맥루의결과가좋지않은것은아마도노쪽피부정맥궁 (cephalic arch) 에대한치료가어려웠기때문인것으로생 각하였다. 풍선성형술후이차개통률은매우좋은것으로보 고되었다. 19, 20 아래팔동정맥루인경우 Manninen 등 20 은 1 년이차개통률은 85% 로보고하였고, Turmel-Rodrigues 등 19 은 1 년이차개통률은 85%, 4 년이차개통률은 77% 로보고 하였다. 위팔동정맥루에서는 1 년이차개통률이 92%, 4 년 이차개통률이 60% 로보고하였다. 19 3. 자가동정맥루의혈전성패쇄의치료 최근영상의학과논문에서는자가동정맥루의혈전성폐 쇄의경우일반적인수술보다혈관내치료 (endovascular treatment) 가더효과적이고조만간자가동정맥루혈전성 폐쇄의절대적표준 (gold standard) 로자리잡게될것으로 21, 22 예측하고있다. 일반적으로성숙된자가동정맥루는인조혈관동정맥루보 다혈전성폐쇄의위험성이떨어진다. 그이유로는첫째, 혈 전성폐쇄가되기위해선매우심한협착과이에따른혈류의 감소가있어야하지만자가정맥의내피세포에서항응혈성 요소 (local anticoagulant factor) 를분비하여느린혈류상 황에서도혈전을예방할수있으며, 둘째, 천천히협착이진 행되어수많은측부혈관 (collaterals) 이발생하여혈류가유 지될수있도록도와주기때문이다. 이처럼자가동정맥루 에서혈전성폐쇄가인조혈관동정맥루보다드물지만일단 혈전이발생하면인조혈관동정맥루에비해혈관내치료의 어려움이있다. 그이유로는첫째, 해부학적으로복잡하여 문합부및협착위치를찾기가어렵고, 둘째, 인조혈관동정 맥루에비해협착이다발성이며, 셋째, 협착이매우심하여 유도철사의통과가어려울수있고, 넷째, 측부혈관이주정 맥유출로로오인받을수있고, 다섯째, 혈전의양이많아모 두제거하기가어려울수있으며특히인조혈관동정맥루에 비해동맥류 (aneurysm) 이많고그내부에있는오래된혈전 은제거하기가어려울수있다. 자가동정맥루혈전성폐쇄에 대한혈관내치료금기 23 로는감염, 미성숙동정맥루, 매우큰 동맥류, 100 cc 이상의혈전이있는경우등이있으나저자의 경험으로는감염만이절대적금기이며그외에는증례에따 라치료방침을정하는것이좋을것으로생각된다. 1) 시술방법 혈전이발생했을때가능하면빨리치료를하는것이좋다. 오래될수록혈관내치료가어려워질수있다. 본격적인치 료전에가능하면샛길조영술이나초음파를시행하여혈전과 협착의위치를확인하는것이치료에도움이된다. 혈전이없 는부위의동정맥루나혈전을직접천자한후조영제를천천 히주입하면혈전사이로조영제가이동하여혈전및협착의 위치를확인할수있다 (Fig. 4). 동정맥문합부에협착이없 고혈전이문합부상부에위치한경우문합부부위에서심장
42 Hanyang Medical Reviews Vol. 31 No. 1, 2011 A B C A Fig. 5. Schemas of puncture site by considering thrombus locations. A) If there is no thrombus (arrowheads) at the cephalic vein adjacent to arteriovenous anastomosis (arrow), an antegrade puncture (star) can be performed just after the anastomotsis. B) If there are thrombi (arrowheads) at the anastomotic site (arrow), a retrograde puncture (star) can be performed just after the thrombus. C) If the thrombi (arrowheads) are clumped together in the fistula, antegrade and retrograde puncture (stars) in the thrombi should be performed. Fig. 4. Diagnostic fistulogram for the thrombosed radiocephalic fistula. Note that there are multiple thrombi (arrows) and multiple stenoses (arrowheads). 쪽으로천자를하고, 문합부까지혈전이있으면혈전상부에 서문합부쪽으로천자를한다. 또한혈전이문합부부위까지 있고혈전상부를천자하기가어렵다면초음파유도하에혈 전을직접천자해야한다. 이경우인조혈관동정맥루혈전성 폐쇄와같이정맥유출부쪽으로천자를하여혈전제거와협 착에대한풍선성형술을한후반대방향으로다시천자하여 문합부쪽의혈전을제거하면된다 (Fig. 5). 본원에서는천 자가된경우 Desilets-Hoffman sheath (COOK, Bloomington, IN, USA) 를삽입한후 10 cc 주사기를연결하여음압을유발시키면서정맥유출부쪽의혈전을흡입 (manual catheter-directed thromboaspiration) 한후 2,000-5,000 단위의헤파린을일시주사하고협착부위에대한혈관성형술을시행한다. 그후처음삽입한 Desilets-Hoffman sheath 상부에추가적인혈관안내도관집 (vascular introducer sheath) 을삽입하고문합부혈전과협착을해결하고있다. 혈전이혈관벽에단단히붙어흡입이되지않는경우 Arrow- Trerotola Percutaneous Thrombectomy Device (PTD; Arrow International, Reading, RA) 를사용할수있다. 24 혈관이 Arrow-Trerotola Percutaneous Thrombectomy Device 보다큰경우회전날이혈전에접촉하지않아효과가없을경우가있으므로손가락으로혈관을눌려주어회전날과접촉할수있게하면효과적으로혈전을부술수이다. 혈전이많은경우 pharmacologic thrombolysis를사용할수있다. 25-28 초음파나샛길조영술로혈전의위치를확인한후스칼프베인세트 (BD Korea Inc., Gyeongsangbukdo, Korea) 또는 angiocatheter (BD Angiocath Plus, BD Korea Inc., Gyeongsangbukdo, Korea) 를삽입한후혈전용해제를주입한다. 혈전용해제로는보통 urokinase를사용하며주입속도는 35,000 U/h 22에서부터 1,200,000 U/h 29
Intervention of the dysfunctional and thrombosed autogenous vascular access 43 B C D E F Fig. 6. A 56-year-old woman with thrombosed radio-cephalic fistula. A, B) The arterial inflow and the venous outflow are blocked by Forgarty catheter (arrow). C) The surgical curette(arrow) scrapes the old thrombi off the radio-cephalic fistula. D) The stenosis is dilated using a 7 mm balloon catheter. E, F) In the post-procedural fistulogram, there are no residual stenosis and thrombi. 까지다양하다. 본원에서는보통 100,000 U에서 200,000 U 의 urokinase를일시주사하고 1시간에서 2시간후남아있는혈전을 Desilets-Hoffman sheath로흡입한다. 혈전의양이많거나오래된혈전인경우혈전용해제를사용해도해결되지않는경우가있어본원에서는다른방법을사용하고있다. 첫째는외과와협진 (joint treatment) 이다. 인터벤션전 문의가동정맥루문합부와정맥유출부를풍선카테터나 5F Forgarty catheter (Edwards Lifesciences, CA, USA) 로차단해혈전이동맥이나폐로이동하지못하게한후, 외과전문의가혈전이있는동정맥루부위를절개해외과용큐렛 (surgical curette) 으로혈전을제거한후, 다시인터벤션전문의가정맥유출부협착부위에대해풍선성형술을시행하
44 Hanyang Medical Reviews Vol. 31 No. 1, 2011 A B D E Fig. 7. A 45-year-old man with thrombosed brachio-cephalic fistula. A) There are large amount of thrombi (arrows) in the brachio-cephalic fistula. B) The blood flow is blocked by Forgarty catheter (arrow). C) The operator's fingers (arrow) are pushing the thrombi out of the fistula. D) In the post-procedural fistulogram, there are no residual thrombi. 는것이다 (Fig. 6). 혈전양이많고혈전이혈관벽에단단히 붙어있는경우유용하다. 둘째는혈전양은많으나급성혈전 으로혈관벽에단단히붙어있지않은경우, 동정맥루문합부 와정맥유출부를풍선카테터나 5F Forgarty Catheter (Edwards Lifesciences, CA, USA) 로차단한후혈전이있는 동정맥루부위를절개한후손가락을사용하여동정맥루혈 전을절개부위로이동시켜제거하는하는방법이다 (Fig. 7). 2) 합병증 폐색전증, 동맥색전증, 정맥박리 (venous dissection), 가성동맥류 (Pseudoaneurysm), 감염등이보고되었다. 16-18 3) 결과 Turmel-Rodrigues 와 Haage 등 21, 22 은각각 50 증례이상 의자가동정맥루혈전성폐쇄의혈관내치료에대해보고하 였다. Turmel-Rodrigues 등 21 은아래팔동정맥루에서성공 률, 1 년일차개통률및 1 년이차개통률이각각 93%, 49%, 81% 였고, 위팔동정맥루에서성공률, 1 년일차개통률및 1 년이차개통률이각각 76%, 9%, 50% 였다. Haage 등 22 이 보고한논문에서는대부분아래팔동정맥루였으며일부위 팔동정맥루가있었고, 성공률, 1 년일차개통률및 1 년이차 개통률이각각 89%, 27%, 51% 였다. 결론기능부전동정맥루치료로풍선성형술후이차개통률은매우좋다. 19, 20 그러나모든협착에서결과가좋은것은아니다. 특히노쪽피부정맥궁협착인경우풍선성형술의결과가좋지않다. 따라서환자의이학적검사, 샛길조영술, 초음파검사등결과를종합적으로판단하여환자의치료방침을결정하는것이좋을것으로생각된다. 자가동정맥루의혈전성패쇄의인터벤션치료는수술적치료와비교했을때치료결과가나쁘지않다. 그러나인조혈관혈전성패쇄보다는혈전의양이많고해부학이복잡하여좀더긴학습곡선 (learning curve) 가필요하다. 감염등과같은시술금기가없다면수술적방법에앞서시도하는것이바람직하다. References 1. ESRD Registry Committee of Korean Society of Nephrology. Current renal replacement therapy in Korea.
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