대한혈관외과학회지 : 제 23 권제 1 호 Vol. 23, No. 1, May, 2007 정맥재건수술의적응및수술결과 성균관대학교의과대학외과학교실, 삼성서울병원혈관외과, 1 경북대학교의과대학경북대학교병원이식 - 혈관외과학교실 노영남ㆍ이경복ㆍ김동익ㆍ김형기 1 ㆍ허승 1 ㆍ김영욱 The Indications and Outcomes of Major Venous Reconstructions Young-Nam Roh, Kyung-bok Lee, Dong-Ik Kim, Hyung-Kee Kim 1, Seung Huh 1 and Young-Wook Kim Division of Vascular Surgery, Department of Surgery, Samsung Medical Center (SMC), Sungkyunkwan University School of Medicine, Seoul, 1 Division of Transplantation & Vascular Surgery, Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea Purpose: We wanted to review our indications and the results of venous reconstructions. Method: We retrospectively investigated the medical records of 64 patients who underwent vein reconstructions between Jan 1992 and Oct 2006 at 2 university hospitals. The clinical outcomes of venous reconstruction were analyzed according to the sites of venous reconstruction, the indications and the venous patency. Result: The indications for venous reconstructions were traumatic vein injury (58%), malignant tumor (28%), Nut-cracker syndrome (9%) and others (5%). The venous reconstruction procedure included graft interposition (48%, 24 vein grafts and 7 prosthetic grafts), lateral venorrhaphy (19%), end-to-end anastomosis (16%), patch angioplasty (6%), vein transposition (9%) and 1 case (2%) of vein bypass. 10 forearm replantations were included among the venous reconstructions. There were 4 mortalities and 4 limb amputations after venous reconstructions. According to the method of venous reconstructions, early venous thrombosis occurred in 3.6%, 7.1% and 37.5% of the patients after venorrhaphy, reconstruction with autologous vein and prosthetic graft, respectively. Conclusion: After venous reconstructions for various indications, we found that the clinical significance was related with an early venous patency, but not with the late patency. Key Words: Vein, Trauma, Replantation, Reconstruction 중심단어 : 정맥, 외상, 재접합, 재건 서 정맥은동맥에비해재건수술을요하는경우가많지는않으나, 다양한경우에서시행되고있는실정이다. 외상성정맥손상은정맥재건수술이시행되는가장대표적인경우중하나로 1차세계대전까지도동맥및정맥손상의치료원칙은결찰술이었다 (1). 그후여러연구에서정맥결찰이동맥과정맥의혈류역학적인면에서의해로운영향이밝혀져 (2-6), 오늘날혈역학적으로안정된정맥손상을동 론 책임저자 : 김영욱, 서울시강남구일원동 50 번지우 135-710, 삼성서울병원혈관외과 Tel: 02-3410-3461, Fax: 02-3410-0040 E-mail: ywkim@smc.samsung.co.kr 반한외상환자에서정맥을결찰하는외과의사는거의없게되었다. 종양과관련된정맥재건술은종양으로인해정맥침범이있거나혈전이발생한경우, 종양적출술중정맥손상이있는경우에서시행된다. 이중에서신세포암이나췌장암과같은종양에서주요정맥의침범이있거나혈전이있는경우에는이미침습된종양에대한수술적위험과장기생존율에미치는영향에대한불확실성으로인해그적응에있어아직논란의여지가있는상태이다 (7,8). 또한 nutcracker syndrome에서와같은해부학적이상이나정맥자체의질환, 의인성정맥손상등에서도정맥재건술이요구된다. 이처럼정맥재건수술은지혈이나사지의기능적회복, 종양의완전적출, 해부학적이상의교정등다양한목적으로시행되어, 그평가또한수술방법이나이식편에따른 51
52 대한혈관외과학회지 : 제 23 권제 1 호 2007 정맥개존율뿐아니라장기부전이나사지보존및기능적회복여부, 종양적출술과연관된근치적절제여부, 정맥자체질환에서정맥재건술의성공여부에대한평가도시행되어야할것이다. 본연구는두개의대학병원에서시행한주요정맥재건수술의후향적조사를통하여그적응증을알아보고, 다양한경우에서의정맥재건술방법에따른수술결과를조사하고자하였다. 대상과방법 1992년 1월부터 2006년 10월까지 2개의종합병원 ( 경북대학교병원 & 삼성서울병원 ) 에서외상또는종양적출술, 수술중정맥손상, 그리고혈관기형, 정맥루등으로정맥재건수술을시행한 64명의환자를대상으로하였다 ( 단치료목적의정맥결찰을시행한환자는제외하였다 ). 의무기록의후향적조사를통하여시행된정맥재건수술의적응증, 수술부위, 수술방법, 수술후결과를조사하였고, 수술결과의평가를위해정맥개존과표적장기 ( 조직 ) 보존, 사지의부종유무를조사하였다. 정맥개존과사지기능의평가는입원당시경과기록과외래기록및시행된초음파와전산화단층촬영결과를통해이루어졌다. 정맥조기폐색은수술후 30일이내에초음파혹은전산화단층촬영상정맥의폐색이확인된경우로정의하였고, 지체보존은감각기능이나운동기능의보존과는상관없이조직괴사에의한대절단이필요치않았던경우로정의하였다. 감각기능과운동기능은병력청취와신체검진으로측정하였고, 객관적측정을위한별도의검사는시행하지않았다. 결과정맥재건수술의적응증을보면외상으로인한정맥재건수술을시행한경우가 37예로 58% 를차지하였고, 수술 적응증, 손상부위별, 재건방법별로정맥재건수술의빈도를조사해보면 Table 1, 2와같다. 정맥재건수술과동반된수술을시행한경우가많았는데, 수술적응별로동반된수술의빈도를조사해보면 Table 3과같다. 외상환자의경우사망한경우가 4예있었고, 정맥조기폐색을보인경우가 3예, 지체절단이필요했던경우가 4예있었다. 외상에의한정맥손상환자들의경우동맥및신경손상, 출혈의정도등동반된손상의중증도가환자의예후에중요한영향을미쳤다. 하대정맥-장골정맥손상의경우신부전등의장기부전이발생한경우가 4예, 사지정맥손상환자에서지체는보존하였으나기능의손상이있었던경우가 11예있었다. 종양적출수술과관련된정맥재건 Table 1. Indications for venous reconstructions Indication of surgery N % Traumatic injury 37 58 Upper extremity vein* 15 Lower extremity vein 12 IVC, iliac vein 8 Portal vein-mesenteric vein 2 Tumor resection 18 28 Portal vein-mesenteric vein 6 IVC 5 Internal jugular vein 4 Femoral vein 1 Subclavian-axillary vein 2 Nut cracker syndrome 6 9 Others 3 5 Catheter-induced 1 Phlegmasia 1 Venous aneurysm 1 *Of 15 cases of upper extremity vein reconstruction, 10 cases were upper extremity replantation surgery (Fig. 1) Fig. 1. Forearm replantation in patient with amputated forearm due to trauma (A, B).
노영남외 : 정맥재건수술의적응및수술결과 53 수술의결과를보면하대정맥, 간문맥, 사지정맥, 경정맥의경우에서정맥조기폐색을보인경우가 2예있었는데, 모두인조혈관을이용하여하대정맥을재건한경우였다 (Table 4). 전체정맥재건수술에서수술방법에따라조기정맥폐색의빈도를조사한결과각각일차봉합술에서는 3.6%, 자가정맥에서는 7.1%, 인조혈관을사용한경우에서는 37.5% 의빈도를보였다. 정맥재건수술은동맥질환과는달리주로외상이나종양절제술에서시행되었으며, 다양한재건방법이사용되고있다. 외상환자에서는정맥뿐만아니라다른동반된손상이예후에중요한영향을미쳤고, 동반수술의빈도가높았다. 종양환자에서절제의근치성을높이기위해주로간문맥, 장간막정맥, 하대정맥, 내경정맥재건이이루어졌다. 재건한정맥의조기폐쇄는인조혈관을이용한재건에서높은빈도를보였지만, 재건한정맥의개존율은임상적인증상과의연관성은미미하였다. 고 정맥재건술은동맥수술처럼흔치는않지만의인성정맥손상을포함한외상성정맥손상또는종양적출술과동 Table 2. Venous reconstruction procedure Procedure N % Interposition graft 31 48 Autologous vein 24 (3*) Artificial graft 7 Venorrhaphy 12 19 End-to-and anastomosis 10 16 Vein patch 4 6 IVC-renal artery replantation 6 9 Vein bypass 1 2 찰 *Saphenous vein spiral composition graft 반한정맥절제, 또는혈관압박증후군등다양한경우에정맥재건술이시행되었음을경험하였다. 정맥은동맥처럼혈류속도가빠르지않고, 호흡에따라변화하며, 쉽게압박될수있다는특징때문에정맥재건수술후혈전혈성으로인한정맥폐색이쉽게발생할수있다고알려져왔다. 그리고동맥과는달리정맥혈류차단시허혈증을초래하는경우가흔치않으므로정맥손상시에는정맥결찰이흔히이용되어왔다. Table 3. Associated procedures with venous reconstructions Indication and location (N) Associated procedure Trauma Upper extremity Arterial reconstruction 12 vein (15) Fasciotomy & skin graft 10 Lower extremity Arterial reconstruction 1 vein (12) AVF closure 1 Fasciotomy 2 IVC-iliac vein (8) Arterial reconstruction 2 Colostomy 1 Portal vein- Pancreaticoduodenectomy 1 mesenteric vein (2) Bowel resection 1 Tumor resection IVC (5) Nephrectomy for RCC 3 Primary IVC tumor resection 2 Retroperitoneal tumor resection 1 Portal vein- Liver lobectomy 2 mesenteric vein (6) Pancreaticoduodenectomy 4 GIST excision 1 Internal jugular RND for recurrent thyroid ca. 4 vein (4) Subclavian vein (2) RND for recurrent thyroid ca. 2 Femoral vein (1) Inguinal dissection for sarcoma 1 IVC = inferior vena cava; RCC = renal cell carcinoma; GIST = gastrointestinal stromal tumor; RND = radical neck dissection N Table 4. Operative complications after venous reconstructions (6 cases of Nut cracker syndromes and other 3 cases were excluded) Complications IVC-iliac Portal-mesenteric Extremity Jugular Trauma Tumor Trauma Tumor Trauma Tumor Trauma Tumor (8) (5) (2) (6) (27) (3) (4) Death 2 0 0 0 2 0 0 Early occlusion (<30 days) 1 2* 0 0 2 0 0 Amputation 1 0 0 0 3 0 0 Organ failure 4 0 0 0 2 0 0 Extremity dysfunction 0 0 0 0 11 0 0 *Artifitial graft
54 대한혈관외과학회지 : 제 23 권제 1 호 2007 그러나사지의외상성손상에서정맥의결찰은동맥과정맥의혈류역학에장애를초래함이점차밝혀지고있다 (9,10). 특히슬와정맥의결찰은급성하퇴부부종과함께하지절단율을증가시킨다고알려져있다 (11,12). 동물실험에의하면대퇴정맥의결찰후대퇴동맥혈류가 50 75% 감소함을발견하였고, 이같은변화는약 72시간지속되었음을보고하였다 (9). 그리고동ㆍ정맥동반손상환자에서정맥의재건을하지않고동맥재건만시행할경우재건된동맥의개존율과사지의구제율이낮았고, 장기적으로는만성적인정맥부전증이발생할수있음이보고되어있다 (10,13,14). Rich 등은전시에서슬동, 정맥동시손상을입은환자에서동맥재건술과함께슬정맥재건술을시행한환자군에서지체절단율을낮출수있었다고보고하였다 (15). 그러나이러한정맥의재건후장기적인개존율에대해서는많이알려져있지않다. 일부보고자들은재건된정맥은궁극적으로혈전으로폐색되기때문에정맥재건을불필요한술식이라고비판하기도한다 (16). 반면 Phifer 등은하지의정맥재건후높은장기개존율을보고하였고 (16), 동맥에서와는달리정맥혈전은재개통되는것을자주관찰하였다고보고하였다 (17,18). 정맥재건후장기개존율은일괄적으로제시되기어렵고재건부위과재건방법에따라다양하게나타나고있다. Kuralay 등은정맥혈류가빠를수록높은장기개존율을보이며, 재건방법에상관없이총대퇴정맥, 표재대퇴정맥, 슬와정맥에서 5년개존율을각각 100%, 78%, 69% 로보고하였다 (19). 그리고슬와정맥이하정맥에대해서는개존율이매우낮아재건이불필요하다고결론지었다 (19). 정맥재건술식에대해서는혈전제거술, 첩포편성형술, 일차봉합술, 이식편간치술, 단단문합술순으로높은 5년개존율을보고하였다 (19). 그러나정맥재건술의유용성은동맥과달리장기적개존율보다는조기개존율에더큰의미가있을수있다. Travis 등에따르면동ㆍ정맥재건술을함께시행한환자에서재건된정맥이막힌다하더라도재건술후첫 2주간정맥혈류유지는재건된동맥의개존율을향상시켜주는효과가있는것으로보고하고있다. 이 2주간의기간은정맥측부혈행이발달할때까지의기간으로추측된다 (16). 외상환자에서사지의재접합수술에대해서는많은논란이있어왔다. 그이유는혈류의재개통만으로성공적인재접합수술이라고단정할수없고, 환자의안전성, 통증유무, 사지기능회복, 일상복귀까지의재활치료기간, 치료비용, 미관상문제등을종합적으로고려하여지체재접합수술시행여부를결정하여야하기때문이다 (20). 외상성하지손상에서의지체재접합수술은하지절단후보조기착용과비교하여수술위험이높고, 재원기간및일상복귀그리고재활기간이길며, 평균 4 7회의재수술이필요하다고알려져있다 (20). 사지재접합수술을시행하기전적절한환자평가를통해재접합수술의성공률이높은환자 를선택하여시행하는것이무엇보다도중요하다. Hanover Polytrauma score에서 1, 2기속하고, 냉허혈시간 (cold ischemic time) 이 4시간을넘지않은환자를지체재접합수술의적응으로권하고있다 (21-23). Hierner 등 (20) 은슬관절이하하지의전절단과아전절단외상환자에서재접합수술후성공률은각각 62.5%, 69.2% 로보고하였다. Romero-zarate 등 (24) 은상지재접합수술후 82% 의성공률과이들중 50% 는만족할만한운동기능의회복을보고하였다. 본연구에서도상지재접합수술후사지구제율은 80% 로나타났지만 Chen classification상 grade I or II 정도의기능회복을보인경우는 20% 에불과하였다. 외상성정맥손상의경우특히골절, 연부조직및신경손상을동반한복합외상환자에서치료후기능회복은혈관뿐만아니라동반된염증, 근골계합병증혹은신경장애가사지기능장애의중요한인자로작용하였으며특히신경손상을동반한경우신경기능의회복이사지기능회복에가장중요한역할을함을경험하였다. 사지혈관이외경부, 흉복부의주요정맥손상은생명을위협하는출혈과함께연관된장기및조직의부전을초래할수있다. 또외상성정맥손상은대부분에서인접동맥및장기손상을동반하는빈도가빈번하므로정맥재건술의개존율뿐아니라출혈로인한사망이나타장기동반손상으로인한전신적문제가더중요시될수도있다. 복부정맥의재건술후정맥의개존율에대해서도알려진바가많지않다. Stone 등 (25) 은외상으로인한간문맥손상에서간문맥을결찰하였을경우에도 80% 의환자생존율과혈관조영술상측부혈행로가잘형성되었음을보고하였다. Janssen 등 (26) 은간외간문맥혈전환자들을분석하여종양이없고, 간경화가없는경우간문맥혈전환자의 1년, 5 년, 10년생존율이각각 95%, 89%, 81% 임을보고하였다. 이 Fig. 2. Portal vein reconstruction after pancreaticoduodenectomy for a patient with pancreas head cancer.
노영남외 : 정맥재건수술의적응및수술결과 55 험많은외과의에의해시행되는것이바람직하고 (7), 반드시자가정맥을이용해야한다고생각한다. Nut Cracker 증후군의수술결과는과거저자등이보고한바있으므로본논문에서는기술하지않았다 (27). 사지의외상환자에서정맥의재건은사지의구제율을높이고, 동반된동맥재건부의개존율을높이는데그의의가있고, 종양의절제술에서는종양의완전절제율을높이는데의의가있으며, 정맥의재건술은정맥의장기적개존율에대한우려없이행해질수있다. 정맥의재건방법에대해서는이번연구에서는인조혈관을사용할경우높은조기폐색율을보였다. 결 론 Fig. 3. Inferior vena cava reconstruction with PTFE graft for a patient with primary leiomyosarcoma arising at caval wall. 는간문맥혈전에의한폐색의경우예후는환자가가진기저질환에의해좌우되며, 문맥고혈압에의해좌우되지않음을의미한다. 간문맥이외다른복부정맥의경우재건술후개존율에대한일괄적인자료는찾기힘들지만이상을바탕으로장기개존율은환자의생존에큰영향을미치지않을것으로예상된다. 종양의적출술중정맥재건을요하는경우는췌-십이지장적출술후간문맥재건술 (Fig. 2), 양측광범위경부곽청술후내경정맥재건술, 일차성하대정맥종양적출술후하대정맥재건술 (Fig. 3), 연부종양육종절제술시주위침범정맥재건술등에서주로이용되었다. 종양수술에서침범정맥절제및정맥재건술을시행하는이유는종양의근치적절제가능성을높이고자하는데주목적이있다. 따라서정맥재건술후측부혈행로가발달되기까지재건된정맥은개존상태를유지한다면정맥재건술의목적은성취한것으로본다. 복강내정맥재건술후정맥의장기개존율은임상적으로의미가크지않은것으로보인다. 본연구결과인조혈관을이용하여하대정맥재건술을시행한환자의장기추적결과모든예에서하대정맥이식편완전폐색을보였으나하지부종등별다른임상증상이없었음을경험하였다. 정맥의재건술을통한종양절제범위의확장이환자의장기적인생존율에미치는영향은아직도증명되지않았다. 췌십이지장절제술의경우표준췌십이지장절제술군과간문맥절제와재건시행군사이에의미있는생존율의차이는발견되지않았다 (7). 췌장암환자에서정맥침범은절제수술의금기는아니지만수술의위험성을고려할때췌-십이지장절제술과동반한간문맥절제및재건술은경 정맥의재건은외상또는종양적출술에서지혈, 사지의구제, 종양의절제범위확장목적으로행하여진다. 사지의혈관손상시정맥재건술은주로상지재접합수술에서시행되었으며전완부접합술에서상지절단을경험하였다. 외상환자에서정맥손상뿐만아니라다른동반된손상이환자의예후와기능회복에많은영향을미쳤다. 종양적출술과동반된정맥재건술에서인조혈관을사용한대정맥재건술후빈번한이식편조기폐색을경험하였으나이에따른임상증상은경미하였음을경험하였다. 전체정맥재건수술에서수술방법에따라각각일차봉합술에서는 3.6%, 자가정맥에서는 7.1%, 인조혈관에서는 37.5% 의조기정맥폐색빈도를보였다. 정맥재건술이종양근치절제의가능성을증가시킬수있지만장기생존율에미치는효과에대해서는향후연구가필요하다고생각된다. REFERENCES 1) Pappas PJ, Haser PB, Teehan EP, Noel AA, Silva MB Jr, Jamil Z, et al. Outcome of complex venous reconstructions in patients with trauma. J Vasc Surg 1997;25(2):398-404. 2) Rich NM, Collins GJ Jr, Andersen CA, McDonald PT. Autogenous venous interposition grafts in repair of major venous injuries. J Trauma 1977;17(7):512-520. 3) Rich NM, Hobson RW, Collins GJ Jr, Andersen CA. The effect of acute popliteal venous interruption. Ann Surg 1976;183(4):365-368. 4) Rich NM, Hobson RW 2nd, Wright CB, Fedde CW. Repair of lower extremity venous trauma: a more aggressive approach required. J Trauma 1974;14(8):639-652. 5) Rich NM, Hughes CW, Baugh JH. Management of venous injuries. Ann Surg 1970;171(5):724-730. 6) Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery 1969;65(1):218-226. 7) Tseng JF, Tamm EP, Lee JE, Pisters PW, Evans DB. Venous resection in pancreatic cancer surgery. Best Pract
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