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J Korean Surg Soc 2011;80:212-220 DOI: 10.4174/jkss.2011.80.3.212 원 저 혈관내치료시대에복부대동맥류의수술적치료의적응과단기치료성적 성균관대학교의과대학삼성서울병원외과학교실혈관외과, 1 영상의학교실, 2 순환기내과학교실 노영남ㆍ박양진ㆍ김동익ㆍ박광보 1 ㆍ도영수 1 ㆍ최승혁 2 ㆍ김덕경 2 ㆍ김영욱 Indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era Young-Nam Roh, M.D., Yang Jin Park, M.D., Dong-Ik Kim, M.D., Kwang-Bo Park, M.D. 1, Young-Soo Do, M.D. 1, Seung Hyuk Choi, M.D. 2, Duk-Kyung Kim, M.D. 2, Young-Wook Kim, M.D. Division of Vascular Surgery, Department of Surgery, Departments of 1 Radiology, 2 Cardiology, Samsung Medical Center (SMC), Sungkyunkwan University School of Medicine, Seoul, Korea Purpose: To assess the role of OR in treatment of AAA patients, we reviewed the indications and our current results of OR of AAA. Methods: We retrospectively investigated the database of 366 patients (mean age, 68.3±8.7 years, male 86%) who underwent open surgical (n=291, 80%) or endovascular treatments (n=75, 20%) of AAA in a tertiary referral center between Sep. 2003 to Aug. 2010. Treatment-related morbidities and mortality rates within 30 days were investigated according to the indications for treatment, clinical features, anatomic location, and underlying causes of AAA. Results: According to the location of AAA, we treated 343 (94%) infrarenal, 17 (5%) juxtarenal and 6 (2%) suprarenal AAAs. Underlying causes of AAA were degenerative (90%), infected (3%), inflammatory (3%), Marfan s syndrome (2%), and vasculitis (0.5%). Clinically, 338 (92%) were non-ruptured and 28 (8%) were ruptured AAAs. 75% of patients were treated with OR after the inception of reimbursement of aortic device while 25% of patients were treated with EVARs. The operative mortality rates of OR was 0.4% in patients with non-ruptured infrarenal AAA, 0% in patients with non-ruptured juxta- and suprarenal AAA and 21.4% in ruptured AAA patients. Conclusion: In an era of endovascular treatment of AAA, we have experienced excellent surgical results after OR in patients with non-ruptured AAA with various clinical features. Though EVAR is rapidly replacing OR in treatment of infrarenal AAAs, OR has its own role in treatment of AAA patients with unfavorable conditions for EVAR. The role of OR should not be underestimated. (J Korean Surg Soc 2011;80:212-220) Key Words: Abdominal aortic aneurysm, Surgical repair, Outcomes 중심단어 : 복부대동맥류, 수술적치료, 결과 서 론 책임저자 : 김영욱, 서울시강남구일원동 50 번지 135-710, 성균관대학교삼성서울병원혈관외과 Tel: 02-3410-3461, Fax: 02-3410-0040 E -mail: ywkim@skku.edu 접수일 :2010 년 11 월 1 일, 게재승인일 :2011 년 2 월 8 일 복부대동맥류에대한치료는 1950년대수술적방법이처음도입된이후수술기구, 대용혈관, 수술기법, 수술전후처치등이많은발전을해왔지만아직도파열되지않 212

Young-Nam Roh, et al:indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era 213 은복부대동맥류에대한계획수술후수술사망률은 2.4 8.4% 로비교적높게보고되고있다.(1-3) 특히복부대동맥류치료목적으로혈관내동맥류치료 (EndoVascular Aneurysm Repair, EVAR) 가도입된이후수술적치료 (Open repair) 의대상환자들은수술에도불리한해부학적조건을가지고있는경우가더빈번해짐으로써복부대동맥류의수술적치료후수술사망률은 2000년대이후에는오히려증가하고있다는보고도있다.(4) EVAR의도입은전체복부대동맥류환자의치료후사망률을낮추는것으로이미잘알려져있으며,(5) 최근 EVAR가널리행해짐에따라일부에서는수술적치료의중요성이저평가되는경향이있다. 2006년미국의통계에따르면전체복부대동맥류환자의약 30% 는수술적방법으로치료되고있으며,(6) 수술적치료는복부대동맥류의치료에서여전히중요한부분을차지하고있다고볼수있다. 저자등은 EVAR 시행이증가하는현시점에서복부대동맥류환자에서수술적치료의적응증과동맥류의원인및위치에따른최근 7년간의수술후조기성적을알아보고자하였다. 방법 2003년 9월부터 2010년 8월까지 7년동안한 3차의료기관에서복부대동맥류로진단된환자 556명중치료를받은 366명의 data base와의무기록을후향적으로조사하였다. 2005년 8월건강보험심사평가원 (Health Insurance Review & Fig. 1. Treatment algorithm for patients with abdominal aortic aneurysm (AAA). Fig. 2. Result of preoperative cardiac evaluation before elective treatment of abdominal aortic aneurysm (AAA) (N= 341). *Percutaneous coronary intervention; Coronary artery bypass grafting.

214 J Korean Surg Soc. Vol. 80, No. 3 Assessment Service, HIRA) 에서신동맥하부의, 직경 5 cm 이상의복부대동맥류환자에대한 EVAR 시술에대해보험급여를시행한이후, 본원에서는복부대동맥류환자에서가능하면 EVAR first policy 를채택하여환자를치료하였다. 본원의복부대동맥류치료방침은 Fig. 1과같았다. EVAR 시행의해부학적적합성기준은 Zenith R Aortic Stent Graft (Cook Company, Bloomington, IL, U.S.A) 의 physician reference manual (2003년) 을따랐다. 치료전심장질환에대한위험도평가를위해계획수술을시행한전례의환자에서심초음파검사와동위원소를이용한심근스캔을시행하였고, 2009년 9월이후에는심초음파검사와관상동맥 CT 조영술 (Coronary CT Angiography, Somatom Definition Flash, Siemens R, Germany) 을시행하였 Table 1. Procedural details of open repair of abdominal aortic aneurysm (AAA) (n=291) Procedures Non-ruptured (n=263) Ruptured (n=28) Status Elective 246 (94%) Emergent 17 (6%) 28 (100%) Approach Transperitoneal 237 (90%) 28 (100%) Retroperitoneal 26 (10%) Aortic clamping Infra-renal 240 (91%) 23 (82%) Supra-renal 18 (7%) 1 (4%) Supra-celiac 5 (2%) 1 (4%) None 3* (11%) Graft material Prosthetic graft 255 (97%) 25 (89%) Cryopreserved aortic allograft 7 (3%) Autogenous arterial patch 1 (0.4%) Bifurcated 200 (76%) 19 (68%) Tube graft 60 (23%) 5 (18%) Axillo-bifem. 1 (0.4%) 1 (4%) Patch 2 (1%) Adjuvant procedure Cholecystectomy 15 (6%) Hypogastric artery reconstruction 22 (8%) Renal artery reconstruction 10 (4%) 1 (4%) Omental wrapping 11 (4%) 1 (4%) Left renal vein division 6 (2%) Closure of enteric fistula 2 (1%) Removal of aortic stent graft 1 (0.4%) 3 (11%) *Intraoperative death before aortic clamping; Autogenous arterial patch of aneurysmal neck for saccular aortic aneurysms due to mycotic origin with hypogastric artery and one PTFE patch. 다. 수술전급성관상동맥증후군의경우와, 안정형협심증이라도관상동맥에 3혈관질환 (3-vessel disease) 이의심될경우, 심근스캔상가역적인큰관류결손 (large reversible perfusion defect) 이발견될경우관상동맥조영술을시행하였다. 수술전심장질환에대한위험평가를시행한결과는 Fig. 2와같았다. 비파열성복부대동맥류환자중위와같은소견으로인해대동맥수술전관상동맥조영술을요했던환자는 15명 (4.4%) 이었고, 이들중 5명에서는복부대동맥류치료전에관상동맥재건술 ( 경피적관상동맥성형술 4예, 관상동맥우회술 1예 ) 을시행하였으며, 1명에서는복부대동맥류수술과관상동맥우회술을동시에시행하였다. 복부대동맥류에대한수술적치료는모든환자들에서전신마취하에시행되었고, 정중절개를통한개복혹은좌측후복막을통한접근을이용해시행하였다. 대동맥재건수술에대한세부사항은 Table 1에기술하였다. 치료후사망은치료후 1개월이내사망한경우로정의하였다. 결과 556명의복부대동맥류환자중치료를받지않은 187명 (34%) 은직경 5 cm 미만의크기가작은복부대동맥류환자 168명, 치료의적응은되었으나환자측이치료를거부한환자 15명, 말기암동반환자 2명, 중증폐결핵환자 1명, 말기간경화환자 1명이있었다. 이들을제외한 369명 (66%) 의환자가복부대동맥류치료를시행받았으며, 이연구에서는동기간중흉복부대동맥류 (Thoraco-abdominal aneurysm) 로수술을시행받은 3명은복부대동맥류에서제외하였다 (Fig. 3). 치료를거부한환자 15명중심폐기능상복부대동맥류수술의고위험군으로판단된환자는 5예였으며그중 2예는본연구기간이후에수술적치료와 EVAR를각각시행받았고, 나머지 3명의환자들은아직치료를받지않은상태이다. 연구에포함된 366명환자의임상적특징은 Table 2, 동맥류병변의특징은 Table 3과같았다. 치료방법으로 291명 (80%) 에서는수술적치료 (Open repair) 가시행되었고, 75명 (20%) 에서는 EVAR가시행되었다. 1명의환자는 EVAR 시행중동맥류파열로수술적치료로전환되었다 (Fig. 4). 국내에서 EVAR의보험급여가이루어진 2005년 8월이후에는 221예 (75%) 의수술적치료와 75예 (25%) 의 EVAR가시행되었다. 221예의수술적치료환자에서 EVAR가시행되지

Young-Nam Roh, et al:indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era 215 Fig. 3. Indications for AAA treatment (Sep. 2003 Aug. 2010). *Thoracoabdominal aortic aneurysm. 못한이유들은 Table 4와같았다. EVAR는급여시행이후신동맥하부의비파열성복부대동맥류에대한치료의 29% (75/263) 로증가하였다. 1) 수술적치료의성적복부대동맥류의평균직경은 6.1±1.5 cm였고, 수술후재원기간의중간값은비파열성의경우 9.0±12.0일, 파열성동맥류의경우 17.0±22.4일이었다. 파열되지않은복부대동맥류의수술후심근경색, 급성신부전, 급성호흡부전증후군, 다발성장기부전, 그리고좌측대장허혈증은각각 5.3%, 3.8%, 4.6%, 1.9%, 1.5% 에서발생하였다. 수술적치료후수술사망률은비파열성복부대동맥류와파열성복부대동맥류에서각각 0.4% ( 신동맥하부대동맥류 0.4%, 신동맥근접혹은신동맥상부대동맥류 0%) 그리고파열성복부대동맥류수술후 21.4% 였다. 비파열성복부대동맥류의수술적치료후수술사망 1예는급성심근경색증에의해좌심실파열이발생한경우였다. 수술적치료의성적은 Table 5에요약되어있다. 고찰 복부대동맥류수술에많은발전이있었음에도불구하고, 비파열성복부대동맥류에서수술적치료의사망률은 2.4 8.4% 로비교적높게보고되고있고, 파열성복부대동맥류의경우에는수술적치료후사망률이 40 60% 에이르는것으로보고되고있다.(1-3,7,8) 복부대동맥류환자의치료에대해국내학회에서빈번한구연발표가있었지만, 실제저자등이근자에발표된논문중수술성적에관한보고는예상외로적었는데, Kim 등 (9) 은계획수술후 6.5%, 응급수술후 26.7% 의수술사망률을보고하였고, Park 등 (10) 은비파열성복부대동맥류의경우 4.4%, 파열성복부대동맥류의경우 35.7% 로보고하였다. 국내에서 EVAR의보험급여인정은다른나라와비교하여비교적늦은시기인 2005년 8월에야이루어졌고그결과임상에서 EVAR의적극적인시술은서구나다른나라에비해상대적으로늦었다고볼수있다. Giles 등 (5) 은 1993년부터 2005년까지의미국에서 Nationwide Inpatient Sample (NIS) 의자료를대상으로한연구에서 EVAR의도입이후수술적치료의사망률은 4.5% 이고, EVAR 후수술사망률은 1.3% 로 EVAR후상대적으로낮은수술사망률을보고하였다. 또한그들은 EVAR의도입이전체복부대동맥류의치료에따른사망률을의미있게감소시켰다고결론지었다 (4.7% vs 3.1%, P<.0001).(5) EVAR와수술적치료를비교한전향적다기관무작위비교연구들은 EVAR의사망률이수술적치료보다의미있게낮다 (1 2% vs. 4 5%) 는사실을통해 EVAR의효과를입

216 J Korean Surg Soc. Vol. 80, No. 3 Table 2. Dermographic and clinical characteristics of 366 patients who underwent open surgical or endovascular repair of abdominal aortic aneurysm (AAA) Characteristics Non-ruptured (n=263) Open repair (N=291) Ruptured (n=28) EVAR (N=75) Total (N=366) Mean age, yr (range) 67.6±9.3 (31 86) 70.3±8.6 (45 81) 70.2±5.9 (59 84) 68.3±8.7 (31 86) Male (%) 218 (83%) 24 (86%) 71 (95%) 313 (86%) Clinical presentation of AAA Asymptomatic pulsating mass 190 (72%) 75 (100%) 265 (72%) Abdominal or back pain 65 (25%) 22 (79%) 87 (24%) Hemorrhagic shock 5 (18%) 5 (1%) Aortic occlusion 2 (0.7%) 2 (0.5%) Infected aneurysm 11 (4%) 1 (4%) 2 (3%) Aorto-enteric fistula 2 (0.7%) 2 (0.5%) Distal artery embolization 2 (0.7%) 2 (0.5%) Comorbidities Hypertension 173 (66%) 19 (68%) 54 (72%) 246 (67%) Coronary artery disease 87 (33%) 7 (25%) 23 (31%) 117 (32%) Prior CABG* 23 (9%) 1 (4%) 4 (5%) 28 (8%) Remote (>6 mo) 14 (5%) 3 (4%) 17 (5%) Recent (<6 mo) incidental 7 (3%) 1 (4%) 1 (1%) 9 (2%) Planned preliminary 2 (0.8%) 2 (0.5%) Prior PCI 32 (12%) 3 (11%) 9 (12%) 44 (12%) Remote (>6 mo) 23 (9%) 3 (11%) 8 (11%) 34 (9%) Recent (<6 mo) incidental 5 (2%) 1 (1%) 6 (2%) Planned preliminary 4 (1.5%) 4 (1%) Medical treatment 35 (13%) 3 (11%) 8 (11%) 46 (13%) Diabetes mellitus 51 (19%) 4 (14%) 14 (19%) 69 (19%) Chronic renal insufficiency 10 (4%) 4 (14%) 1 (1%) 15 (4%) S Cr 2 3 mg/dl 7 (3%) 3 (11%) 10 (3%) S Cr >3 mg/dl 2 (0.7%) 1 (4%) 3 (1%) Dialysis-dependent 1 (0.4%) 1 (1%) 2 (0.5%) COPD >Moderate 20 (8%) 7 (9%) 27 (7%) Symptomatic CVD 24 (9%) 1 (4%) 8 (11%) 33 (9%) Malignant tumor 29 (11%) 4 (14%) 13 (17%) 46 (13%) *Coronary artery bypass grafting; Percutaneous coronary intervention; Chronic obstructive pulmonary disease; Post-bronchodilator FEV 1/FVC<70% and FEV 1<80% predicted; Cerebrovascular disease; Stomach cancer, 17; Colon cancer, 7; Lung cancer, 4; Prostate cancer, 5; Renal cell cancer, 4; Bladder cancer, 3; Liver cancer, 2; Head & Neck cancer, 2; Breast cancer, 2. 증하고자하였다. The Dutch Randomized Endovascular Aneurysm Management (DREAM) trial은수술사망률 (<30 일 ) 보고에서 EVAR 1.2%, 수술적치료 4.6% 로보고하였고 (P=.10),(11) EVAR trial 1도수술사망률비교에서 EVAR 1.7%, 수술적치료 4.7% 로보고하였다 (P=.009).(12) 이들다기관전향적연구중 EVAR trial 1에서는 60세이하환자를, DREAM trial에서는염증성복부대동맥류, 결체조직질환등의환자들을제외하였으며, 두연구모두해부학적으로 EVAR가가능하다고판단되는환자만을대상으로한치료의결과였다. 지금까지의두치료방법의비교연구결과수술적치료와비교하여 EVAR는단기생존율, 중증합병증발생률측면에서더우수한성적을보였고, 고령환자에서지속적인생존율증가를보인다는관찰결과에근거하여 EVAR의역할은더커졌다고볼수있으며이와함께수술적치료의역할은축소된것은사실이다.(13) 그리고 EVAR의경우계속적인기기의발달과함께그치료성적이향상된것이사실이지만수술적치료방법은기술적으로이미완성된치료법으로오랫동안지속되어왔다. 본연구결과에따르면 2005년 8월이후저자등이경험

Young-Nam Roh, et al:indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era 217 Table 3. Lesion characteristics of 366 patients who underwent open surgical or endovascular treatment of abdominal aortic aneurysm (AAA) Characteristics Intact (n=263) Open repair (n=291) Ruptured (n=28) EVAR (n=75) Total (N=366) Etiology Degenerative 233 (89%) 23 (82%) 75 (100%) 331 (90%) Inflammatory 10 (4%) 2 (7%) 12 (3%) Infected 10 (4%) 2 (7%) 12 (3%) Marfan s syndrome 9 (3%) 9 (2%) Takayasu s arteritis 1 (0.4%) 1 (0.3%) Behcet disease 1 (4%) 1 (0.3%) Anatomic location Infrarenal 241 (92%) 27 (96%) 75 (100%) 343 (94%) Juxtarenal 16 (6%) 1 (4%) 17 (5%) Suprarenal 6 (2%) 6 (2%) Fig. 4. A patient who required open conversion during EVAR. (A) Completion angiogram during EVAR shows extravasation of contrast agent after deployment of the aortic stent graft with suprarenal fixing device. (B) An operative finding of ruptured abdominal aortic aneurysm (AAA) showing aortic stent graft. (C) Excised aortic stent graft device (Zenith R ): suprarenal stents were removed during the operation. (D) Follow-up CT angiogram shows abdominal aortic and the left renal artery reconstructions. 한전체복부대동맥류치료환자 296명중해부학적원인 (164예, 55%), 환자나이 <60세 (17예, 6%), 파열성대동맥류 (17예, 6%), 세균감염성대동맥류 (5예, 2%), Marfan 증후군 (7예, 2%), 신기능저하환자 (3예, 1%) 등의원인으로 EVAR의적응증에서제외된환자의수는 221명으로전체의 75% 를차지하였음을경험하였다. 최근 EVAR 기기의점차적인개선에힘입어 EVAR 시술의해부학적적응증이확장되었고분지형 (Branched) 또는 Fenestrated stent graft, Iliac Branched Device (IBD) 등이개발되어있고, 최근에는 stent graft의직경도더다양하게개발되었지만, 국내에서는아직도이같은모든제품의사용이허가되어있지는않은실정에있다. 특히분지형또는 Fenestrated stent graft, Iliac Branched Device (IBD) 등새로운기기의장기성적에대해서는아직규명되어야할부분이남아있다고생각된다. 복부대동맥류에대한일차치료로서 EVAR가합리화된

218 J Korean Surg Soc. Vol. 80, No. 3 Table 4. Reasons for infeasibility of EVAR in AAA patients (N=221*) Reasons No (%) Anatomical reason Proximal neck Angulation>60 o 32 (11%) Length<15 mm 32 (11%) Diameter<18 mm or >28 mm 13 (4%) Distal aortic diameter<17 mm 7 (2%) Iliac artery Unavailable to preserve 1 hypogastric artery 34 (11%) due to iliac artery aneurysms Small diameter (<7.5 mm) or occlusion 18 (6%) Common iliac artery length<10 mm 10 (3%) Juxtarenal or suprarenal AAA 16 (5%) Thrombotic occlusion of AAA 2 (1%) Physiologic or clinical reason Age<60 years 17 (6%) Ruptured AAA 17 (6%) Infected aneurysm 5 (2%) Marfan s syndrome 7 (2%) Contrast allergy or scr>2.5 mg/dl 3 (1%) Symptomatic AAA due to impending rupture 5 (2%) Combined with type B thoracic aortic dissection 2 (1%) Patient refuse 1 (0.3%) *Patients number after inception of reimbursement for aortic stent graft. 것은무작위비교연구에서수술적치료의사망률이 EVAR 에비해의미있게높았다는사실에근거하고있다. 그러나이들다기관무작위전향적비교연구에서의복부대동맥류의수술적치료후수술사망률은단일기관연구들이보고한 1.0 2.4% 에비해상대적으로높게보고되었으며,(1,14-16) 여러연구에서신동맥하부의비파열성복부대동맥류의수술적치료후 1% 내외의사망률을보고한사실에비추어볼때,(14,15) 다기관연구보고의수술적치료후사망률이높게나타난사실은우리가주목할만한점이다. 본연구에서도비특이성 ( 퇴행성 ) 원인에의한신동맥하부복부대동맥류환자의계획수술후수술사망률은 0.4% (1/241) 로낮았음을경험하였다. 복부대동맥류의수술사망률은술자의경험과병원의복부대동맥수술환자수와상관관계가있음이보고되어있다.(17-21) 이는수술적치료뿐만아니라 EVAR의경우도마찬가지였다.(21) 경험이많은센터에서는수술시불필요한박리와출혈량, 수술시간, 기술적인결함을줄일수있다고생각되며, 수술중마취과의사그리고수술후심장 Table 5. Postoperative morbidity and mortality after open abdominal aortic aneurysm (AAA) repairs (n=291) Complications Non-ruptured (n=263) Ruptured (n=28) Acute myocardiac infarction* 14 (5.3%) 4 (14.2%) Acute renal failure 10 (3.8%) 9 (32.1%) Acute respiratory distress 12 (4.6%) 13 (46.4%) syndrome Multi-organ failure 5 (1.9%) 10 (35.7%) Leg artery embolism 2 (0.8%) 1 (3.6%) Ureteral injury 2 (0.8%) Left colon ischemia 4 (1.5%) 3 (10.7%) Bleeding required reoperation 6 (2.3%) Thoracic spinal cord ischemia 1 (0.4%) 1 (3.6%) Operative mortality 1/263 (0.4%) 6/28 (21.4%) Infrarenal AAA 1/241 (0.4%) 6/27 (22.2%) Juxtarenal & suprarenal AAA 0/22 (0%) 0/1 (0%) Infected AAA 0/10 (%) 1/2 (50%) Inflammatory AAA 0/10 1/2 (50%) Marfan s syndrome 0/9 Aorto-enteric fistula 0/2 (0%) *According to WHO diagnostic criteria; Serum Cr level elevatio n>50% of preoperative level; Ventilator care for>3 days after surgery; Except mortality cases. 혹은신장내과와의긴밀한협조가수술사망률을줄일수있는요인이라생각된다. 본원에서는수술전모든복부대동맥류환자에서순환기내과전문의가수술에대한환자의심장합병증위험도평가를하고있으며, 고위험군환자 (n=15) 에서관상동맥조영술을대동맥류치료전먼저시행하였고이들중 6예에서는관상동맥병변에대한치료를시행하였다. 과거의보고들에서안정성관상동맥질환은복부대동맥수술전예방적관상동맥재관류술을시행하여도환자생존율향상이나심근경색의발생빈도를감소시키지않았음이이미보고되어있었다.(22-24) 그러나복부대동맥류계획수술을요하는환자에서불안정성관상동맥질환이나좌심실기능이현저히떨어진환자에서는복부대동맥류수술전관상동맥재건술이먼저고려될수있다.(23) 본연구에서수술전심장질환에대한검사를통해고위험군환자에서는복부대동맥류수술을연기하고관상동맥재건술을먼저시행한것도복부대동맥류수술후수술사망률을낮추는데기여하였을것으로추측된다.

Young-Nam Roh, et al:indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era 219 결 EVAR First Policy 에도불구하고본원에서복부대동맥류에대한치료로서수술적치료가여전히많이시행되었다. 그리고비파열성복부대동맥류에대한수술적치료의사망률은 1% 이하로낮았음을경험하였다. EVAR가각광받고점점널리행해지고있는현시점에서 EVAR의기술, 기기발전, 교육이중요한것은당연하다. 복부대동맥류의수술적치료는 EVAR와는다른적응과역할을가지므로 EVAR의그늘에서저평가되어서는안된다고생각된다. 따라서복부대동맥류의수술적치료에대한교육이등한시되지않고 EVAR와함께지속적인발전을해야한다고생각된다. 론 감사의글 이논문의 data 정리를도와주신우영간호사께감사드립니다. REFERENCES 1) Lloyd WE, Paty PS, Darling RC, 3rd, Chang BB, Fitzgerald KM, Leather RP, et al. Results of 1000 consecutive elective abdominal aortic aneurysm repairs. Cardiovasc Surg 1996;4: 724-6. 2) Aune S. Risk factors and operative results of patients aged less than 66 years operated on for asymptomatic abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2001;22:240-3. 3) Starr JE, Hertzer NR, Mascha EJ, O'Hara PJ, Krajewski LP, Sullivan TM, et al. Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms. J Vasc Surg 1996;23:870-80. 4) Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 2006;43:205-16. 5) Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg 2009;49:543-50; discussion 50-1. 6) Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009;50:722-9 e2. 7) Lawrence PF, Gazak C, Bhirangi L, Jones B, Bhirangi K, Oderich G, et al. The epidemiology of surgically repaired aneurysms in the United States. J Vasc Surg 1999;30:632-40. 8) Mureebe L, Egorova N, Giacovelli JK, Gelijns A, Kent KC, McKinsey JF. National trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2008;48:1101-7. 9) Kim YC, Yun IJ, Ha JW, Yang HK, Ahn H, Kim SJ. 10 year experiences of surgically treated abdominal aortic aneurysm patients. J Korean Surg Soc 1996;12:167-75. 10) Park YJ, Lee JH, Ha J, Chung JW, Park JH, Kim SJ. 118 cases of abdominal aortic aneurysm (AAA) repair. J Korean Surg Soc 2003;65:441-6. 11) Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607-18. 12) Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. 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;364:843-8. 13) Schermerhorn ML, O'Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008;358:464-74. 14) Hertzer NR, Mascha EJ, Karafa MT, O'Hara PJ, Krajewski LP, Beven EG. Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg 2002;35:1145-54. 15) Menard MT, Chew DK, Chan RK, Conte MS, Donaldson MC, Mannick JA, et al. Outcome in patients at high risk after open surgical repair of abdominal aortic aneurysm. J Vasc Surg 2003;37:285-92. 16) Sicard GA, Reilly JM, Rubin BG, Thompson RW, Allen BT, Flye MW, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg 1995;21:174-81; discussion 81-3. 17) Hannan EL, Kilburn H Jr, O'Donnell JF, Bernard HR, Shields EP, Lindsey ML, et al. A longitudinal analysis of the relationship between in-hospital mortality in New York State and the volume of abdominal aortic aneurysm surgeries performed. Health Serv Res 1992;27:517-42. 18) Dardik A, Lin JW, Gordon TA, Williams GM, Perler BA. Results of elective abdominal aortic aneurysm repair in the 1990s: A population-based analysis of 2335 cases. J Vasc Surg 1999;30:985-95. 19) Katz DJ, Stanley JC, Zelenock GB. Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience. J Vasc Surg 1994;19:804-15; discussion 16-7. 20) Kazmers A, Jacobs L, Perkins A, Lindenauer SM, Bates E. Abdominal aortic aneurysm repair in Veterans Affairs medical centers. J Vasc Surg 1996;23:191-200.

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