Original Article J Korean Soc Radiol 2020;81(2):409-417 https://doi.org/10.3348/jksr.2020.81.2.409 pissn 1738-2637 / eissn 2288-2928 Safety and Efficacy of the Percutaneous Manual Aspiration Thrombectomy Technique to Treat Thrombotic Occlusion of Native Arteriovenous Fistulas for Hemodialysis 혈액투석용자가혈관동정맥루의혈전을동반한폐색에서경피적수동흡인혈전제거술의안정성과유용성 Sang Eun Yoon, MD 1, Sun Young Choi, MD 1,2 *, Soo Buem Cho, MD 2,3 1 Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea 2 Department of Radiology, Ewha Womans University College of Medicine, Seoul, Korea 3 Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea Received June 19, 2019 Revised August 18, 2019 Accepted August 24, 2019 *Corresponding author Sun Young Choi, MD Department of Radiology, Ewha Womans University College of Medicine, 25 Magokdong-ro 2-gil, Gangseo-gu, Seoul 07804, Korea. Tel 82-2-2650-5179 Fax 82-2-2650-5302 E-mail medmath@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ORCID ids Sang Eun Yoon https:// orcid.org/0000-0002-2472-8691 Sun Young Choi https:// orcid.org/0000-0003-2488-1183 Soo Buem Cho https:// orcid.org/0000-0001-5762-7064 Purpose To evaluate the safety and efficacy of the percutaneous manual aspiration thrombectomy technique to treat thrombotic occlusion of native arteriovenous fistulas. Materials and Methods A retrospective review of 20 patients who underwent percutaneous manual aspiration thrombectomy for native thrombotic arteriovenous fistula occlusion from March 2012 to December 2017 was performed. We evaluated technical and clinical success rates and complications. The primary and secondary patency rates were calculated using the Kaplan-Meier analysis. Results Percutaneous manual aspiration thrombectomy was performed in 20 patients (n = 20) with concomitant balloon angioplasty. The overall technical and clinical success rates were both 85% (n = 17). The native arteriovenous fistulas, based on their site, were the left radiocephalic (n = 13), left brachiocephalic (n = 4), and right radiocephalic (n = 3) fistulas. An underlying stenosis was detected in the juxta-anastomotic venous site (n = 16), outflow draining vein (n = 12), and central vein (n = 4). The primary and secondary patency rates at 1, 3, 6, and 12 months were 100%, 70.6%, 70.6%, and 56.5% and 100%, 94.1%, 94.1%, and 86.9%, respectively. There were no complications associated with procedure. Conclusion Percutaneous manual aspiration thrombectomy is a safe and effective method to treat thrombotic native arteriovenous fistula occlusion. Index terms Arteriovenous Fistula; Thrombosis; Thrombectomy Copyrights 2020 The Korean Society of Radiology 409
혈액투석동정맥루에서의수동흡인혈전제거술 서론 혈액투석이필요한만성신부전환자에서적절한혈역학적경로를유지하는것은환자생존에필수적이다. 이러한환자의대부분에서장기간의혈액투석이요구되고있어, 동정맥루를통해혈액투석을시행하는것이일반적이다. 인조혈관에비하여자가혈관을이용한동정맥루의장기개통률이높은것은잘알려진사실이나, 드물지않게자가혈관동정맥루에도혈전을동반한폐색이발생한다 (1-3). 과거자가혈관동정맥루에서혈전을동반한폐색이발생한경우수술을통한재개통술을시행하는것이일반적이었으나, 협착을동반하는경우가많기때문에, 수술을통한재개통술의성공률이낮고재개통에성공하더라도혈류가유지되는기간이비교적짧아서, 재개통술자체를시행하지않고새로운동정맥루를만드는경우가흔하였다 (3-5). 하지만최근환자들의평균수명이증가함에따라현재유지하고있는동정맥루의개통률을높이는것이매우중요한이슈가되었고, 이러한흐름에맞추어다양한경피적혈관내시술법이소개되었다 (6-9). 대표적인경피적혈관내시술법으로, 혈전용해제를이용한도관유도혈전용해술 (catheter directed thrombolysis) 과경피기계적혈전제거술 (percutaneous mechanical thrombectomy) 이있다. 하지만, 도관유도혈전용해술의경우우로키나아제 (urokinase) 와같은혈전용해제의사용에따른출혈등중요합병증이발생할위험이있고, 만성혈전의제거에제한이있다는단점이있다 (9-12). 또한경피기계적혈전제거술의경우자가혈관에사용했을경우혈관내막의손상위험이있고, 고가의기구사용에따른의료비상승의문제까지있어그사용이제한되고있다 (13, 14). 이에연구자들은자가혈관동정맥루폐색환자에서혈전용해제와기계적혈전제거술기구를사용하지않은경피적수동흡인혈전제거술 (percutaneous manual aspiration thrombectomy) 의유용성에대해평가하고자한다. 대상과방법 연구대상 2012년 3월부터 2017년 12월까지혈액투석용동정맥루기능부전으로내원하여경피적혈관내시술을시행한환자중혈전을동반한자가혈관동정맥루폐색환자를대상으로분석하였다. 이연구는후향적으로진행되었고, 모든환자에서시술과관련된동의서를사전에받았으며, 본원기관생명윤리심의위원회로부터연구에대한승인을받았다 (EUMC 2019-01-022). 분석요인대상환자들의자가혈관동정맥루수술시기, 동정맥루문합에이용된혈관명칭및위치, 동반된협착부위등에관해조사하였다. 시술성적은미국인터벤션영상의학회 (Society of Interventional Radiology) 의보고표준 (reporting standards) 을적용했으며, 기술적성공률, 임상적성공률, 1차및 2차개통률, 그리고시술과연관된합병증에대하여분석하였다 (15). 기술적성공은자가혈관동정맥루내의혈전이제거되고혈류가회복되며잔존협착이 30% 미 410 jksronline.org
대한영상의학회지 2020;81(2):409-417 만인경우로정의하였다. 임상적성공은시술후최소한한차례이상정상적으로투석을재개할수있었던경우로정의하였다. 1차개통은경피적혈전제거술직후부터동정맥루에혈전이재발하여경피적혈관내시술을다시시행한날까지의기간으로정의하였으며, 2차개통은경피적혈전제거술직후부터동정맥루기능부전으로수술적치료를시행하였거나, 신장이식등의이유로동정맥루사용을중지한날또는환자가추적검사에서사라진날까지의기간으로정의하였다. 통계적분석은 SPSS 20.0 software (IBM Corp., Armonk, NY, USA) 를이용하였으며, Kaplan- Meier method를이용하여 1차및 2차개통률을분석하였고, p-value 가 0.05 이하인경우통계적으로유의한것으로판단하였다. 경피적수동흡인혈전제거술초음파로동정맥루의혈전위치를확인한후, 2% lidocaine ( 휴온스리도카인염산염수화물주사 2%, Huons, Seongnam, Korea) 으로국소마취후 21-gauge micropuncture set (Coaxial Micro- Stick R Set, Medcomp, Harleysville, PA, USA) 를이용하여혈관을천자한다. 혈관천자의방향은혈전의분포에따라결정된다. 혈전의분포는크게동정맥루문합부위 (juxta-anastomosis site) 에근접한배출정맥 (draining vein) 에국한된경우, 원위부배출정맥에국한된경우, 그리고동정맥루문합부위부터배출정맥까지긴분절에걸쳐분포하는경우로나눌수있다. 첫번째경우는, 혈류가유지되고있는근위부혈관의한곳을통하여동정맥루문합부위를향해혈류의역방향으로천자를한다 (Fig. 1). 두번째경우는, 동정맥루의혈류가유지되는배출정맥의한곳을통하여중심정맥을향하여정방향으로천자를한다. 세번째경우는, 혈전으로폐색이있는배출정맥의두곳을통하여중심정맥을향한정방향천자와동정맥루문합부위를향한역방향천자를모두시행한다. 이때두천자부위사이에혈전이있는배출정맥분절이중첩되어포함되도록천자한다. 혈관이천자되면, 유도철사를이용하여 7-F Desilets-Hoffman Sheath (Desilets-Hoffman Introducer Set, Cook, Bloomington, IN, USA) 를삽입한후 7-F Desilets-Hoffman Sheath (Cook) 를통하여소량의조영제를천천히주입하여혈관내혈전의분포를확인한다. 이후 7-F Desilets-Hoffman Sheath (Cook) 를혈관내깊게삽입한후 10 cc Luer-Lock syringe (BD 10 ml Luer-Lock Tip Syringe, Becton Dickinson and Company, Tuas Avenue, Singapore) 를이용하여수동으로음압을형성한상태에서천천히뒤로이동시키면서혈전흡입을반복하여시행한다. 혈전제거술을시행후동정맥루조영술을시행하여잔류혈전의분포및동반된협착유무를평가한다. 잔류혈전이동정맥루문합부위에남아있는경우 5.5-F Fogarty catheter (Fogarty R Occlusion Catheter, Edwards Lifesciences, Irvine, CA, USA) 를이용하여혈전제거술을시행한다. 잔류혈전이원위부배출정맥에남아있는경우, 혈관직경보다 1 mm 큰구경의풍선카테터를이용하여잔존혈전을분쇄시켜혈전제거술을시행한다. 동반된협착이있는경우, 혈관직경보다 1 mm 큰구경의풍선카테터를이용한혈관성형술 (balloon angioplasty) 을시행한다. 혈관직경은동정맥루조영술을통하여획득한주변정상혈관의직경을기준으로삼는다. 동정맥루조영술에서혈류가원활하게관찰되며잔존협착이 30% 미만으로관찰될때까지풍선혈관성형술을반복적으로시행한다. 최종적으로, 촉진을통해동정맥루를통한혈류를확인한후, 동정맥루조영술을시행하여동정맥루 https://doi.org/10.3348/jksr.2020.81.2.409 411
혈액투석동정맥루에서의수동흡인혈전제거술 문합부위부터중심정맥까지원활한혈류를확인하면시술을종료하고, sheath 는즉시제거하며, 천자부위는봉합하여지혈한다. 모든환자에서시술전 Pethidine 25 mg (Demerol; Jeil Pharmaceutical, Seoul, Korea) 및 heparin 3000 IU ( 중외헤파린나트륨주사액, JW Pharmaceutical, Fig. 1. Percutaneous manual aspiration thrombectomy of a radiocephalic AVF in the left forearm. A. Fistulography of the AVF shows total occlusion of the radiocephalic AVF. B. Percutaneous manual aspiration thrombectomy was performed using negative pressure from a syringe through the 7F Desilets-Hoffman Sheath. C. In the follow-up fistulography, most of the thrombus is removed and the AVF is recanalized. A long segmental stenosis is observed in the juxta-anastomotic venous site and draining cephalic vein. D. Balloon angioplasty was performed for the long segmental stenosis along the juxta-anastomotic venous site and draining cephalic vein using a 5 mm 4 cm balloon catheter. E. Completion fistulography showed relatively patent flow through the radiocephalic AVF. AVF = arteriovenous fistula A B C D E 412 jksronline.org
대한영상의학회지 2020;81(2):409-417 Seoul, Korea) 을정맥주입하였고, 예방적항생제는사용하지않았다. 결과 2012년 3월부터 2017년 12월까지혈액투석용동정맥루기능부전으로혈관내시술을시행받은환자는모두 644예 (n = 328) 이며, 이중자가혈관동정맥루기능부전환자는 427예 (n = 227) 이고, 인조혈관동정맥루기능부전환자는 217예 (n = 101) 이었다. 자가혈관동정맥루기능부전환자 427 예 (n = 227) 중혈전을동반한동정맥루폐색으로시술을받은환자는 20예 (n = 20) 이며, 20예모두경피적수동흡인혈전제거술을시행하였다. 환자들의중위연령은 69.5세 ( 범위, 49~89세 ) 이었고, 성별은남자 11명, 여자 9명이었다. 동정맥루사용기간의중간값은 52.5개월 ( 범위, 18~174개월 ) 이었고, 평균추적관찰기간은 28.9개월 ( 범위, 5~51개월 ) 이었다. 그리고이전에경피적혈관내시술을평균 1회 ( 범위 0~8 회 ) 시행하였다. 동정맥루위치는좌측요골두정맥루 (radiocephalic fistula) 가 13명, 좌측상완두정맥루 (brachiocephalic fistula) 가 4명, 우측요골두정맥루가 3명이었다. 전체 20명환자모두에서한부위이상의동반된협착부위가관찰되었으며총협착부위는 32예이며, 이중문합부주위정맥 (juxta-anastomotic venous site) 협착이 16예, 원위부배출정맥 (outflow draining vein) 협착이 12예, 그리고중심정맥 (central vein) 협착이 4예였다. 요골두정맥루환자 16명은문합부주위정맥협착이 13예, 원위부배출정맥협착이 11예, 중심정맥협착이 2예동반되었고, 상완두정맥루환자 4명은문합부주위정맥협착이 3예, 원위부배출정맥협착이 1예, 중심정맥협착이 2예동반되었다. 한편, 두정맥궁 (cephalic arch) 협착은총 3명에서동반되었는데, 요골두정맥루환자 1명과상완두정맥루환자 2명에서두정맥궁협착이동반되었다. 총 20명의환자모두에게서경피적수동흡인혈전제거술을시행하였고, 혈전용해제나기계적혈전제거술기구는사용하지않았다. 5.5-F Fogarty catheter (Edwards Lifesciences) 를함께사용하여혈전제거술을시행한경우는 13명이었으며, 모든 20명의환자에서풍선혈관성형술을함께시행하였다. 환자의임상양상에대한내용은 Table 1에정리하였다. 20명의환자중 17명의환자는성공적으로혈전이제거되어혈류가정상적으로회복되었고 ( 기술적성공률 85%), 17명환자모두시술직후혈액투석이정상적으로시행되었다 ( 임상적성공률 85%). 경피적수동흡인혈전제거술이실패한 3명의환자는모두동정맥루문합부위정맥에만성혈전이있었던환자들로, 유도철사가이만성혈전을통과하지못하여서혈전제거에실패하였다. 3명의환자모두이전에경피적혈관내시술을시행한적은없었다. 이 3명의환자는수술적혈전제거술을시행하였으나, 모두수술적혈전제거술에실패하여동정맥루조성술을시행하였다. 이연구에서 1차및 2차개통률은 1, 3, 6, 12개월에서각각 100%, 70.6%, 70.6%, 56.5% 및 100%, 94.1%, 94.1%, 86.9% 이었다 (Fig. 2). 시술과관련된합병증은없었다. 고찰 혈액투석용자가혈관동정맥루의혈전을동반한폐색은대부분특정부위의협착과이로인해 https://doi.org/10.3348/jksr.2020.81.2.409 413
혈액투석동정맥루에서의수동흡인혈전제거술 Table 1. Characteristics of Thrombotic Occlusion of Native AVFs Treated with Percutaneous Manual Aspiration Thrombectomy AVF site (%) Parameter Value Radiocephalic, left forearm 13 (65) Brachiocephalic, left upper arm 4 (20) Radiocephalic, right forearm 3 (15) Median age of AVF at procedure (months) 69.5 ± 43.7 Previous interventions for AVF (number) 0 12 (60) 1 3 (15) 2 3 (15) 4 1 (5) 8 1 (5) Underlying stenosis site (%) 32 (100) Juxta-anastomotic venous site 16 (50) Outflow draining vein 12 (37.5) Central vein 4 (12.5) Concomitant balloon angioplasty (%) 20 (100) Concomitant thromboaspiration with a Fogarty catheter (%) 13 (65) AVF = arteriovenous fistula 1.0 0.8 Secondary Patency 0.6 0.4 Patency Primary 0.2 0.0 Primary patency Secondary patency Primary patency-censored Secondary patency-censored 0 10 20 30 40 50 60 Months Fig. 2. Primary and secondary patency rates of percutaneous manual aspiration thrombectomy calculated using the Kaplan-Meier method. 발생한혈류의정체로인해발생한다. 협착이발생하는발병기전은매우다양하며, 자가혈관동정맥루위치에따라호발부위도다르다 (16). 한예로, 요골두정맥루는주로동정맥루문합부주위정맥에협착이발생하고, 상완두정맥루는주로두정맥궁에협착이발생한다 (16). 일반적인동정맥루의협착은문합부주위정맥에과도한혈류에의한압력으로혈관내막층의내피세포와중막층의평활근세포에손상이생기고, 이로인해산화적스트레스및염증과연관된성장인자들, 예를들면엔도텔린 (endothelin), 혈소판유래성장인자 (platelet-derived growth factor), 변환성장인자-베타 414 jksronline.org
대한영상의학회지 2020;81(2):409-417 (transforming growth factor-β) 와사이토카인 (cytokine) 의분비가촉진되어평활근세포가내막으로이동하고증식하여결국신생내막이증식되어혈관에협착이발생하는것으로알려져있다 (17, 18). 그런데, 동정맥루의위치에따라다른원인들이추가로작용하여동정맥루의위치에따른협착호발부위가달라지게된다. 우선동정맥루를통과하는혈류량을살펴보면, 전완에형성한동정맥루에비해서상완에형성한동정맥루를통한혈류량이상대적으로많다. 혈류가두정맥궁까지도달하는시간측면에서는상대적으로상완에형성한동정맥루의경우가혈류의도달시간이짧다. 여기에두정맥궁이그전후정맥들사이에서예각을형성하는주행으로인해정맥의혈류방향이빠르게변화하고, 정맥판막등이더해져난류가발생하게되어, 상완에형성한동정맥루의경우두정맥궁부위에협착이호발하게된다 (19-21). 이외에도, 내피세포와평활근세포를손상시키는의원성원인들이있는데, 대표적인예로투석을위한반복되는천자가있다 (17). 이연구는경피적혈관내시술법을사용한기존연구들과결과를비교할때기술적및임상적성공률은비교적대동소이하였고, 1차및 2차개통률은기존의연구들에비해비슷한추이를보이거나비교적우위에있는경향을보였다 (6-9, 22-24). 또한, 이연구는 1개월이내에재발한환자가한명도발생하지않아, 저자들의시술방법이동정맥루내에잔존혈전을모두효과적으로제거한것에기인한다고생각하였고, 기존연구들과차별화된이연구의장점이라고판단하였다. 다만이연구에서대상환자군중상완두정맥루환자의비율이낮고, 동반된두정맥궁협착비율역시낮은것도시술결과에영향을주었을것으로생각할수있다 (25). 혈전용해제와기계적혈전제거술기구를사용하지않은경피적수동흡인혈전제거술은기존의경피적혈관내시술법과비교하여여러가지장점이있다. 첫째, 우로키나아제등혈전용해제를사용하지않아출혈의발생가능성이현저히낮다. 둘째, 기계적혈전제거술에서사용하는기구들을사용하지않아혈관내피손상을최소한으로줄이면서동시에환자들의경제적부담을덜어주게된다. 이연구에서혈전을흡입하기위하여사용한 7-F Desilets-Hoffman Sheath (Cook) 는, 혈전흡입이비교적용이하고동시에혈관내막손상의위험이비교적적은적절한구경이라고판단된다. 이연구에는몇가지한계점이있는데첫째, 후향적연구이며, 둘째, 환자수가 20명이고시술건수도 20개로비교적숫자가적다는점이다. 앞으로자가혈관동정맥루폐색에서보다효과적이고안전한치료방법을찾기위해서는더많은환자수를대상으로, 여러경피적혈관내시술법들을비교하는전향적연구가필요할것으로생각된다. 이연구에서경피적수동흡인혈전제거술의시술성공률과개통률은경피적혈관내시술법을사용한기존연구와비교했을때비교적좋은결과를나타냈고, 경피적수동흡인혈전제거술과관련된어떠한부작용도나타나지않았으며, 상대적으로환자의경제적부담을경감시켜주었다. 결론적으로, 혈액투석용자가혈관동정맥루에서혈전을동반한폐색의치료로서경피적수동흡인혈전제거술은안전하고, 유용한시술방법이다. Author Contributions Conceptualization, C.S.Y.; data curation, all authors; formal analysis, C.S.Y., Y.S.E.; investigation, C.S.Y., Y.S.E.; methodology, C.S.Y.; project administration, C.S.Y.; resources, C.S.Y., Y.S.E.; software, https://doi.org/10.3348/jksr.2020.81.2.409 415
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대한영상의학회지 2020;81(2):409-417 22. Maleux G, De Coster B, Laenen A, Vaninbroukx J, Meijers B, Claes K, et al. Percutaneous rheolytic thrombectomy of thrombosed autogenous dialysis fistulas: technical results, clinical outcome, and factors influencing patency. J Endovasc Ther 2015;22:80-86 23. Yang CC, Yang CW, Wen SC, Wu CC. Comparisons of clinical outcomes for thrombectomy devices with different mechanisms in hemodialysis arteriovenous fistulas. Catheter Cardiovasc Interv 2012;80:1035-1041 24. Won JH, Bista AB, Bae JI, Oh CK, Park SI, Lee JH, et al. A venotomy and manual propulsion technique to treat native arteriovenous fistulas occluded by thrombi. AJR Am J Roentgenol 2012;198:460-465 25. Turmel-Rodrigues L, Pengloan J, Rodrigue H, Brillet G, Lataste A, Pierre D, et al. Treatment of failed native arteriovenous fistulae for hemodialysis by interventional radiology. Kidney Int 2000;57:1124-1140 혈액투석용자가혈관동정맥루의혈전을동반한폐색에서경피적수동흡인혈전제거술의안정성과유용성 윤상은 1 최선영 1,2 * 조수범 2,3 목적혈액투석용자가혈관동정맥루의혈전을동반한폐색에서경피적수동흡인혈전제거술의안전성과유용성에대해평가하고자한다. 대상과방법 2012년 3월부터 2017년 12월까지자가혈관동정맥루의혈전을동반한폐색으로내원하여경피적혈관내시술을시행받은 20명의환자를후향적으로분석하였다. 기술적및임상적시술성공률, 1차및 2차개통률, 그리고시술에따른합병증을분석하였다. 결과총 20명의환자에서 20회의경피적혈관내시술을시행하였다. 모든환자에서혈전을제거하기위해경피적수동흡인혈전제거술을시행하였고, 협착이동반된경우풍선카테터를이용한혈관성형술을함께시행하였다. 17명의환자는혈전이제거되어혈류가정상적으로회복되었고 ( 기술적성공률 85%), 17명환자모두시술직후혈액투석이정상적으로시행되었다 ( 임상적성공률 85%). 동정맥루위치는좌측요골두정맥루가 13명, 좌측상완두정맥루가 4명, 우측요골두정맥루가 3명이었다. 동반된협착부위는문합부주위정맥이 16예, 원위부배출정맥이 12예, 중심정맥이 4예였다. 1차및 2차개통률은 1, 3, 6, 12개월에서각각 100%, 70.6%, 70.6%, 56.5% 및 100%, 94.1%, 94.1%, 86.9% 였다. 시술과관련된합병증은없었다. 결론혈액투석용자가혈관동정맥루에서혈전을동반한폐색의치료로서경피적수동흡인혈전제거술은안전하고유용한시술이다. 1 이화여자대학교목동병원영상의학과, 2 이화여자대학교의과대학영상의학교실, 3 이화여자대학교서울병원영상의학과 https://doi.org/10.3348/jksr.2020.81.2.409 417