대한혈관외과학회지 : 제 26 권제 1 호 Vol. 26, No. 1, May 2010 내장동맥분리재건술을이용한흉복부대동맥류재건술 3 예 포항성모병원외과 1, 경북대학교의학전문대학원외과학교실 2, 흉부외과학교실 3 최향희 1 ㆍ김형기 2 ㆍ김근직 3 ㆍ이종태 3 ㆍ허승 2 Separate Visceral Revascularization in Thoracoabdominal Aortic Aneurysm Repair: Report of 3 Cases Hyang Hee Choi, M.D. 1, Hyung Kee Kim, M.D. 2, Gun Jik Kim, M.D. 3, Jong Tae Lee, M.D. 3 and Seung Huh, M.D. 2 Department of Surgery, Pohang St. Mary s Hospital 1, Pohang, Division of Vascular and Transplantation Surgery, Department of Surgery 2, Department of Thoracic and Cardiovascular Surgery 3, Kyungpook National University School of Medicine, Daegu, Korea Thoracoabdominal aortic aneurysm (TAAA) involving the roots of the celiac, superior mesenteric and both renal arteries is a rare, but potentially lethal disease. The overall postoperative mortality rate is high even when the intact TAAA is electively repaired. Furthermore, the postoperative complications are often serious and they include acute renal failure, paraplegia, respiratory distress and intestinal ischemia. The inclusion technique using a visceral-aortic patch (VAP) is considered the gold standard method for visceral artery revascularization for the treatment of TAAA. However, the inclusion technique is not feasible for patients with Marfan syndrome or for those patients with inappropriate anatomy for VAP. In such cases, separate visceral revascularization is a useful alternative and this may decrease the visceral ischemic time. Herein we report on 3 cases of TAAA, and the patients all underwent successful separate visceral revascularization, including one patient with Marfan syndrome. Key Words: Thoracoabdominal aortic aneurysm, Visceral arteries, Revascularization 중심단어 : 흉복부대동맥류, 내장동맥, 혈관재개통술 서 흉복부대동맥류는흉부대동맥과복강내주요장기에혈류를공급하는복강동맥, 상장간막동맥, 신장동맥들이분지하는부위의복부대동맥까지포함된광범위한대동맥류로파열시환자의사망이나심각한합병증발생이불가피하며, 따라서환자의생명연장을위해서는동맥 접수일 : 2010년 3월 16일, 수정일 : 2010년 4월 19일, 승인일 : 2010년 4월 26일책임저자 : 허승, 대구시중구동덕로 200 우 700-721, 경북대학교병원외과 Tel: 053-420-6520, Fax: 053-421-0510 E-mail: shuh@knu.ac.kr 이논문의요지는 2009년대한혈관외과학회춘계학술대회에서발표되었음. 론 류의파열이발생하기전에수술과같은계획된치료가필수적인질환이다. 최근분지형스텐트-이식편 (branched stent-graft) 을사용한혈관내치료와스텐트-이식편삽입술및비해부학적동맥우회술을함께시행하는 hybrid repair 등이개발되어고식적인수술에비하여우수한초기성적들이보고되고있으나 (1-4), 아직이러한치료법들이국내뿐아니라전세계적으로광범위하게사용되기는어려워현재까지흉복부대동맥류의표준치료법은전통적인흉복부절개를이용한대동맥전치환술로여겨지고있다. 현재흉복부대동맥류수술시내장동맥재건술에많이사용되는수술방법은복강동맥및상장간막동맥기시부와우측신장동맥기시부를포함한내장동맥-대동맥첩포 (visceral aortic patch, VAP) 를한꺼번에인조혈관이식편에문합하는 inclusion technique 이며, 이때경우에따라좌측신장동맥기시부까지한꺼번에문 48
Hyang Hee Choi, et al:separate Visceral Revascularization in TAAA Repair 49 Table 1. Characteristics of 3 patients with thoracoabdominal aortic aneurysm Case 1 Case 2 Case 3 Sex/age M/31 F/57 F/58 Etiology Dissection, marfan Degenerative Dissection Crawford type III III III Previous operation Cabrol operation None A-aorta replacement CABG D-aorta replacement Proximal anastomosis T6 level T6 level Distal to SCLA Reattachment of intercostal arery T8-L1 level T8-T12 level T8-L1 level CPB time (minutes) 323 153 347 Ventilator care (days) 3 1 4 Complication Wound pain None Wound pain Acute pyelonephritis CPB = cardiopulmonary bypass; A = ascending; CABG = coronary artery bypass graft; D = descending; SCLA = subclavian artery. 합할수도있다 (5). 이에반해각각의내장동맥들을대동맥이식편에따로따로분리해서재건할수있는데, 이방법은흉복부대동맥류가말판증후군과같은결체조직질환이있는환자에서발생한경우 (5,6), 기시부의병변이나해부학적상황에따라한꺼번에문합하기어려운경우 (7), inclusion technique으로흉복부대동맥류수술후 VAP 부위에동맥류가재발한경우등에서사용할수있으며 (8), 또한일부수술자들은복강내주요장기의허혈시간을감소시키기위한목적으로도시행하고있다 (9). 저자등은최근말판증후군에동반된 1예를포함한 3 예의흉복부대동맥류수술시인조혈관간치술을이용한내장동맥분리재건술을시행하였기에이를문헌고찰과함께보고하고자한다. 증례환자들에대한요약은 Table 1과같다. 증례 1 31세남자로갑작스럽게발생한흉통및냉한을주소로본원을방문하였다. 환자는내원 11년 8개월전말판증후군에동반된윤상대동맥확장증과 A형대동맥박리로본원에서응급으로 Cabrol 수술시행받았으며, 이후내원 10년 1개월전상부하행대동맥치환술, 내원 2년 4 개월전세균성심내막염으로치료받았고, 내원 9개월전에는급성심근경색증으로관상동맥우회술을본원에서시행받았다. CT-혈관조영술 (computed tomography coronary angiography) 에서 III형박리성흉복부대동맥류로진단되었으며, 흉부및복부대동맥류의최대직경은각각 9 cm, 7 cm였고, 우측장골동맥의혈류가저하된소견이관찰되었다 (Fig. 1A). 또한이전하행대동맥이식편주위 로조영제의누출과혈종이증가하는양상이관찰되었다. 수술은전신마취하에흉복부절개를통하여시행하였으며, 심장폐우회로 (cardiopulmonary bypass, CPB) 는좌심방과좌측대퇴동맥을이용한좌심우회술 (left heart bypass, LHB) 을시행하였다. 이전의하행대동맥이식편을노출하고, Mattox 술기를사용하여복부대동맥류및내장동맥기시부를노출하였다 (Fig. 1B). 이후복강동맥상방에겸자를하여복강내장기의혈류를원위부로부터유지하면서이전의흉부이식편에 20 mm 관형및 16 8 mm 갈래형 Dacron 이식편을사용하여미리만들어두었던분지형이식편을문합하고늑간동맥을이식편의측면에재이식하였다. 내장동맥재건술은복강동맥, 상장간막동맥, 우측신장동맥, 좌측신장동맥순으로시행하였다. 복강동맥을대동맥으로부터분리후이식편의한갈래에문합하는동안상장간막동맥의혈류를유지하여복강내장기의허혈을최소화하고자하였으며, 이후복강동맥으로혈류를재관류시키고상장간막동맥을이식편의갈래에문합하였다 (Fig. 1C). 양측신장동맥을재건후이식편의원위부를우측총장골동맥에문합하고, 이후좌측총장골동맥을이식편의측단에문합하여대동맥전치환술을종료하였다 (Fig. 1D). 환자는수술후한달간의입원치료후수술창통증을제외한심각한합병증없이퇴원하였으며, 현재술후 16개월째외래를통하여경과를관찰중이다. 증례 2 57세여자로건강검진에서발견된고혈압에대한검사중대동맥류의심되어본원으로전원되었다. 과거력에서특이사항없었으며, CT-혈관조영술에서하행대동맥및복부대동맥의최대직경이각각 7 cm, 6 cm인 III형흉복부대동맥류가발견되었다 (Fig. 2A). 첫번째환자와마찬가
50 대한혈관외과학회지 : 제 26 권제 1 호 2010 Fig. 1. 31-year-old male patient with Marfan syndrome. He previously underwent Cabrol operation, proximal descending aortic replacement and coronary artery bypasses. Preoperative 3D image of CT angiography shows a type III thoracoabdominal aortic aneurysm with dissection originated from descending aorta to right common iliac artery (A). Two photos show operative findings of dissection (B) and revascularization (C) of visceral arteries. Postoperative MIP image of CT angiography shows well-functioning aortic and visceral arterial grafts (D). Fig. 2. 57-year-old female patient with a type III thoracoabdominal aortic aneurysm (TAAA). Preoperative 3D image of CT angiography shows a TAAA from proximal descending aorta to both common iliac arteries (A). A photo shows operative finding of aortic and visceral arterial reconstruction (B). Postoperative MIP image of CT angiography shows well-functioning aortic and visceral arterial grafts (C). 지방법으로 LHB 준비후수술을시행하였으며, 18 mm 관형및 2개의 16 8 mm 갈래형 Dacron 이식편으로미리만들어두었던분지형이식편을사용하여복강내혈류를재건하였다 (Fig. 2. B, C). 환자는수술후 14일째별다른합병증없이퇴원하였으며, 현재술후 13개월째외래를통하여경과관찰중이다. 증례 3 58세여자로갑작스럽게발생한흉통과목과등의방사통을주소로지역병원에서검사한흉부 CT에서대동맥박리진단받고본원응급실로전원되었다. 과거력에서 특이사항없었으며, CT-혈관조영술에서좌측외장골동맥까지박리된 I형대동맥박리로진단되었다. 응급으로 28 mm Dacron 이식편을사용하여상행대동맥치환술을시행하였다. 수술 1주후시행한 CT-혈관조영술에서하행대동맥및복부대동맥의최대직경은각각 7.5 cm, 5.0 cm 으로증가된소견이관찰되었으며, 가성내강에서혈류를공급받고있던좌측신장의관류가감소된소견이관찰되었다 (Fig. 3A). 환자상태가호전되기를기다려술후 26일째 2차수술을시행하였다. 수술은마찬가지방법으로시행되었으며, 18 mm 관형및 16 8 mm 갈래형 Dacron 이식편으로미리만들어두었던분지형이식편을사
Hyang Hee Choi, et al:separate Visceral Revascularization in TAAA Repair 51 Fig. 3. 58-year-old female patient with type I aortic dissection. She previously underwent emergent ascending aortic replacement. Preoperative 3D image of CT angiography shows dissecting aortic aneurysm extending left external iliac artery and hypoperfusion of left kidney (white arrow) (A). A photo shows operative finding of aortic and visceral arteries including a left accessory renal artery (B). Postoperative MIP image of CT angiography shows well- functioning aortic and visceral arterial grafts, and restored left renal perfusion (C). 용하여복강내혈류를재건하였다. 좌측신장동맥은인접해있던부신장동맥과함께대동맥-신장동맥첩포를이용하여이식편의측면에문합하였으며 (Fig. 3B), 수술후좌측신장의관류는회복되었다 (Fig. 3C). 환자는술후 26일째퇴원하였으나, 퇴원후 2주째수술창통증으로경피적신경차단술시행받았으며, 1개월및 10개월째급성신우신염으로입원하여각각 2주간항생제치료를시행받았다. 재입원시시행한 CT에서이식편의기능은원활하였으며, 이식편주위로감염의증거는없었다. 환자는현재술후 12개월째외래를통하여경과관찰중이다. 고찰흉복부대동맥류의수술후조기사망률은동맥류의범위, 원인, 동반질환, 환자의연령, 수술방법, 수술자의경험, 센터의우수성등에따라차이가있으나 (5,10), 근래수술중관리의발달및수술기법의개선으로 10% 미만으로보고되고있으며 (11-13), 하반신마비와같은중증의합병증도 LHB의사용으로 5% 미만으로감소되고있다 (14). 이러한흉복부대동맥류의수술은 1956년 Creech 등 (15) 에의해처음으로성공적으로이루어졌으며, 이후 Crawford 등 (7) 에의해내장동맥-대동맥첩포 (visceral aortic patch, VAP) 를이용한 inclusion technique이사용되면서획기적인전환점을마련하게되었다. 그러나 VAP을사용함으로써전체적인수술시간은감소하였으나간, 비장, 위장관, 신장등의복강내장기및척수의허혈시간은오히려증가되어수술중대동맥혈류의차단으로야기되는여러장기의허혈에따른합병증은아직까지해결되지못하고있다. Ballard 등 (9,16) 은흉부대동맥의측면을부분겸자후원위부혈류를유지하면서미리만들어두었던세갈래형이식편을흉부대동맥에측단문합하고이후이식편의세갈래분지를복강동맥, 상장간막동맥, 좌측신장동맥에각각문합하는방법을사용하여이들장기의허혈시간을 10 13분정도로감소시킬수있음을보고하였으며, 또한이러한수술방법을사용하여 32예의 III형및 IV형흉복부대동맥류수술후수술사망률 6.3%, 하반신마비 6.3%, 일시적인신부전증 6.3% 등으로장기허혈증으로인한합병증의빈도를감소시킬수있었다고보고하였다. Ballard 등 (9,16) 이근위부흉부대동맥으로부터의혈류를유지하여장기허혈시간을감소시킨것과는달리저자등이사용한방법은 LHB을이용하여원위부로부터복부대동맥의혈류를유지하면서복강동맥, 상장간막동맥, 양측신장동맥을차례로문합하는방법을사용하였다. 흉복부대동맥류수술시복부장기의혈류를유지하기위하여 LHB를이용한원위부대동맥관류법 (distal aortic perfusion, DAP) 과도관을이용한선택적관류법 (selective organ perfusion, SP) 이표준적으로사용되고있으나, 최근 Hanssen 등 (17) 은이러한관류법을이용하여흉복부대동맥류를수술한경우에도수술중복강내장기의저관류및전신적인염증반응으로인하여장관의점막손상을피할수없음을보고하였다. 그러나본증례에서는수술중복강동맥을겸자시간의색조변화는관찰되지않았으며, 마찬가지로복강동맥재관류후상장간막동맥을겸자시에도장관의허혈성변화는관찰되지않았다. 또한상장간막동맥에서강한역출혈 (back bleeding) 이관찰되어복강동맥과상장간막동맥간의동맥우회로가존재할경우저자등이사용한 LHB와순차적겸자법을이용
52 대한혈관외과학회지 : 제 26 권제 1 호 2010 한내장동맥분리재건술이복강내장기의허혈을방지하는데도움이됨을알수있었다. 말판증후군과같은결체조직질환환자에게서발생한흉복부대동맥류인경우에는대동맥벽의병적인상태로인하여내장동맥의분리문합이불가피하며, 대동맥을겸자시대동맥벽의파열을방지하기위하여각별한주의가필요하다. 저자등도말판증후군환자인첫번째증례수술중상장간막동맥을겸자시얇아진대동맥벽으로인하여상장간막동맥기시부의파열이발생하여상당량의출혈을경험하였다. Mommertz 등 (6) 은흉복부대동맥류를동반한 22명의말판증후군환자에서내장동맥분리재건술을시행하여수술사망률 0%, 2 72 ( 중앙값 38) 개월동안의생존율 100%, 후기합병증으로수술후 6년후발생한내장동맥첩포동맥류 1예를보고하였다. 좌심우회술과순차적겸자법을이용한내장동맥분리재건술은말판증후군환자나해부학적으로대동맥-내장동맥첩포문합술이어려운흉복부대동맥류환자에서사용될수있으나, 전체수술시간이길어지고순차적겸자시대동맥벽손상이나대동맥내의혈전에의한색전증이발생할수있으므로이술식이필요한환자에서선택적으로사용되어야한다. 또한이러한수술방법이복부장기및척수의허혈시간을감소시켜흉복부대동맥류의수술후합병증을감소시킬수있을지에대해서는향후보다많은연구가있어야할것으로생각된다. REFERENCES 1) Reilly LM, Chuter TA. Endovascular repair of thoracoabdominal aneurysms: design options, device construct, patient selection and complications. J Cardiovasc Surg (Torino) 2009; 50:447-460. 2) D'Elia P, Tyrrell M, Sobocinski J, Azzaoui R, Koussa M, Haulon S. Endovascular thoracoabdominal aortic aneurysm repair: a literature review of early and mid-term results. J Cardiovasc Surg (Torino) 2009;50:439-445. 3) Bakoyiannis C, Kalles V, Economopoulos K, Georgopoulos S, Tsigris C, Papalambros E. Hybrid procedures in the treatment of thoracoabdominal aortic aneurysms: a systematic review. J Endovasc Ther 2009;16:443-450. 4) Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: hybrid versus open repair. J Vasc Surg 2009;50:15-22. 5) Safi HJ, Huynh TT, Estrera AL, Miller CC 3rd. Thoracoabdominal aortic aneurysm. In: Rutherford RB, editor. Vascular surgery. 6th ed. Philadelphia: Elsevier Saunders; 2005. p.1490-1511. 6) Mommertz G, Sigala F, Langer S, Koeppel TA, Mess WH, Schurink GW, et al. Thoracoabdominal aortic aneurysm repair in patients with marfan syndrome. Eur J Vasc Endovasc Surg 2008;35:181-186. 7) Crawford ES, Snyder DM, Cho GC, Roehm JO Jr. Progress in treatment of thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries. Ann Surg 1978;188:404-422. 8) Tshomba Y, Melissano G, Civilini E, Setacci F, Chiesa R. Fate of the visceral aortic patch after thoracoabdominal aortic repair. Eur J Vasc Endovasc Surg 2005;29:383-389. 9) Ballard JL. Thoracoabdominal aortic aneurysm repair with sequential visceral perfusion: a technical note. Ann Vasc Surg 1999;13:216-221. 10) Cowan JA Jr, Dimick JB, Henke PK, Huber TS, Stanley JC, Upchurch GR Jr. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes. J Vasc Surg 2003;37:1169-1174. 11) Chiesa R, Melissano G, Civilini E, de Moura ML, Carozzo A, Zangrillo A. Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned. Ann Vasc Surg 2004;18:514-520. 12) Gloviczki P. Surgical repair of thoracoabdominal aneurysms: patient selection, techniques and results. Cardiovasc Surg 2002;10:434-441. 13) Kim KH, Ahn H. Surgical treatment of thoracoabdominal aortic aneurysm. Korean J Thorac Cardiovasc Surg 2000;33: 886-893. 14) Coselli JS. The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms: current techniques and results. Semin Thorac Cardiovasc Surg 2003;15:326-332. 15) Creech O Jr, Debakey ME, Morris GC Jr. Aneurysm of thoracoabdominal aorta involving the celiac, superior mesenteric, and renal arteries: report of four cases treated by resection and homograft replacement. Ann Surg 1956;144:549-573. 16) Ballard JL, Abou-Zamzam AM Jr, Teruya TH. Type III and IV thoracoabdominal aortic aneurysm repair: results of a trifurcated/two-graft technique. J Vasc Surg 2002;36:211-216. 17) Hanssen SJ, Derikx JP, Vermeulen Windsant IC, Heijmans JH, Koeppel TA, Schurink GW, et al. Visceral injury and systemic inflammation in patients undergoing extracorporeal circulation during aortic surgery. Ann Surg 2008;248:117-125.