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대한혈관외과학회지 : 제 26 권제 2 호 Vol. 26, No. 2, August 2010 만성하지허혈환자의 TASC II C, D 대퇴 - 슬와동맥병변에대한혈관내치료와우회수술간의예후비교 경희대학교의학전문대학원 / 의과대학외과학교실 1, 영상의학교실 2 신성환 1 ㆍ권세환 2 ㆍ조진현 1 ㆍ안형준 1 ㆍ오주형 2 ㆍ박호철 1 Outcomes of Bypass Surgery Versus Endovascular Therapy for TASC II C and D Femoro-Popliteal Lesions in Patients with Chronic Limb Ischemia Sung Hwan Shin, M.D. 1, Se Hwan Kwon, M.D. 2, Jin Hyun Cho, M.D. 1, Hyung Joon Ahn, M.D. 1, Joo Hyung Oh, M.D. 2 and Ho Chul Park, M.D. 1 Departments of Surgery 1, Radiology 2, Kyung Hee University School of Medicine, Seoul, Korea Purpose: We wanted to define the appropriate treatment modalities for Trans-Atlantic Inter-Society Consensus (TASC) II C and D femoro-popliteal lesions. So we compared the primary patency rate and several clinical factors between percutaneous balloon angioplasty with or without stenting (PTA/S) and bypass surgery (BP). Methods: We reviewed the medical records of patients who underwent BP or PTA/S for TASC II C (BP-C, PTA/S-C) and D (BP-D, PTA/S-D) femoro-popliteal lesions from March 2001 to May 2009. We analyzed the primary and secondary patency rates, and the major limb salvage rates. Results: Eighty two limbs in 74 patients (mean age: 68.7±10.2 years, males: 82.9%) were treated (PTA/S-C: 18, PTA/S-D 19: BP-C 12, BP-D 33). The mean follow-up duration was 30.0±19.0 months. The twenty four month primary patency rates was 82.4% for PTA/S-C and 73.3% for BP-C (P=0.876), and 45.3% for PTA/S-D and 66.6% for BP-D (P=0.034). The twenty four month secondary patency rates were 88.2% for PTA/S-C and 73.3% for BP-C (P=0.669), and 54.7% for PTA/S-D and 73.3% for BP-D (P=0.077). The twenty four month major limb salvage rates were 100.0% for PTA/S-C and 75.0% for BP-C (P=0.030) but there were no statistical differences between the TASC II D groups (P=0.377). Conclusion: Bypass surgery is a preferred initial therapeutic option for TASC II D femoro-popliteal lesions. However, several clinical factors must be carefully considered when selecting the primary treatment modality for TASC II C lesions. Key Words: Peripheral arterial occlusive disease, Femoro-popliteal lesion, Endovascular therapy, Bypass surgery 중심단어 : 말초동맥폐색증, 대퇴 - 슬와병변, 혈관내치료, 우회로술 서 론 접수일 : 2010년 4월 7일, 수정일 (1차: 2010년 6월 16일, 2차 : 2010년 8월 9일 ), 승인일 : 2010년 8월 11일책임저자 : 안형준, 서울시동대문구회기동 1 우 130-702, 경희의료원외과 Tel: 02-958-8246, Fax: 02-966-9366 E-mail: whipple@hanafos.com 이논문은 2010 ASVS에서포스터발표되었음. 대퇴-슬와동맥폐색증에의한하지의허혈증상은 60 70대이상의남자에서주로나타나며그원인은대부분죽상동맥경화증으로최근우리나라에서도고령화와고혈압, 당뇨, 고지혈증등위험인자를가진인구가증가함에따라죽상동맥경화증에의한만성하지허혈환자들이증가하고있다. 증세는간헐적파행부터 90

Sung Hwan Shin, et al:management of TASC II C & D Femoro-Popliteal Lesions 91 심한경우하지의괴사까지나타날수있으며, 이에대한치료는금연이나운동같은고식적치료방법외에풍선이나스텐트를이용한혈관내치료와우회로를이용한수술적치료방법이있으며, 최적의치료는병변의침범정도와증상, 혈관내치료의적응증및환자의전신상태등을고려하여결정하여야한다 (1,2). 혈관내치료의발전은만성동맥폐색증환자들의치료에많은변화를가져왔으나일상생활을저해할정도의휴식기동통이나허혈성괴사를보이는환자들에서수술을시행할지혈관내치료를시행할지에대해서는논란이있다 (3,4). 본연구는 TransAtlantic Inter-Society Consensus (TASC) II classification(4) C, D 그룹의동맥폐색증환자들에서혈관내치료를시행했을때와우회수술을시행했을때의개존율과하지구제율및합병증을비교하고, 위험인자들이개존율에끼치는영향을알아보고자시행하였다. 방법 2001년 3월부터 2009년 5월까지경희대학교의학전문대학원외과학교실에서치료를받은대퇴-슬와동맥의만성폐색성질환환자중혈관내치료를받은환자 146 명 (150 하지 ) 과우회수술을받은환자 126명 (130 하지 ) 가운데환자들을선별하였다. 혈관내치료를받은환자군에서는혈전용해술만시행한경우, 표재대퇴동맥보다근위부혈관에만시술한경우를제외하였고, 우회수술을받은환자에서는대동맥-대퇴동맥우회술, 대퇴동맥간우회술, 혈전제거술및동맥내막절제술만시행한경우와관찰기간내에타병원에서일차수술이시행되었던경우는제외하였다. TASC II C, D군에포함되면서일차적으로혈관내치료를받은환자 33명 (37 하지 ) 과우회수술을받은환자 41명 (45 하지 ) 을최종대상으로하였고, 이환자들의의무기록을분석하였다. 대퇴- 슬와동맥의 TASC II C 병변은혈관협착이나폐색의총길이가 15 cm 이상이거나두번의혈관내중재적시술이후에생긴, 치료를요하는재발성병변으로정의하였고, TASC II D 병변은슬와동맥을포함하면서병변의총길이가 20 cm 이상인만성폐색이나슬와동맥과경골, 비골동맥분지부의근위부를포함한병변으로정의하였다 (3). Distal runoff score는혈관조영술에서치료받은병변으로부터원위부의 50% 미만의협착을보이는혈관의개수로정의하였고 (5), 원위부혈관의폐색정도를 0 3으로나누고문합부하방분지들의기여도를 1 3으로나누어평가하여기여도와폐색정도를곱한것을각각더한후기저저항인 1을더하여 resistance value를계산하는 modified runoff scoring system를이용하였다 (6). 위급사지허혈 (critical limb ischemia, CLI) 은말초동 맥질환에서만성허혈성휴식기통증이나궤양, 괴사등의피부병변이 2주이상나타나는경우로정의하였다 (4). 경피경관혈관성형술의성공은잔여협착정도가 30% 미만인경우를기술적성공이라간주하였고, 임상적성공은발목상완지수 (ankle-brachial index, ABI) 가시술전에비해 0.1 이상증가하였을경우, Rutherford category(6) 1부터 4까지의환자들은 clinical category가 1 이상개선된경우, 그리고 category 5와 6의환자들은 category 3 이하로되면서궤양의치유를보일경우로정의하였다. 일차개존의성공은협착의재발이없고, 추가적인중재적시술없이막히지않은경우로하였고, 임상증상이악화되고 50% 이상재협착을보여추가적인시술을시행했던경우의누적개존율을이차개존율로간주하였다. 외래추적관찰은 3 6개월간격으로신체검사와 ABI를검사하였으며 1년에한번듀플렉스초음파검사나컴퓨터단층촬영을이용한혈관조영술을시행하였다. 추적관찰기간중파행증이악화되는등재발이의심되는증상이있는경우는바로상기검사를시행하였다. 하지의구제는조직의괴사로인한발목이상의하지절단이없는경우로정의하였다. 일차개존율과하지구제율은 Kaplan-Meier 분석법을이용하였고, 각군간의비교는 log rank test를이용하였다. 자료분석은 SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 결과 1) 연구대상군의임상적특징평균추적관찰기간은 30.0±19.0개월, 환자들의평균나이는 68.7±10.2세, 그중에남자가 68명으로 82.9% 를차지하였다. TASC II C에속하며혈관내치료를받은군 (percutaneous transluminal balloon angioplasty with or without stenting, PTA/S-C) 은 18 하지, 우회수술을받은군 (bypass surgery, BP-C) 은 12 하지였고, TASC-II D에속하며혈관내치료를받은군 (PTA/S-D) 은 19 하지, 우회수술을받은군 (BP-D) 은 33 하지로, 각각에서성별이나추적관찰기간에통계적으로의미있는차이는없었다 (Table 1). 두군간의위험인자및동반질환비교에서 PTA/S군이 BP군에비해당뇨병의빈도및치료전 ABI 값이의미있게높았고 (P=0.002, P=0.014), 나머지인자 ( 흡연, 고혈압, 말기신부전증, 허혈성심장질환, 고지혈증, 뇌혈관질환 ) 에서는양군간에차이가없었다 (Table 1). 2) 위험인자에따른일차개존율의차이전체환자를대상으로증상의정도를 Rutherford category로분류했을때파행증을보인경우가 35 하지,

92 대한혈관외과학회지 : 제 26 권제 2 호 2010 Table 1. Patient demographics PTA/S (n=37) BP (n=45) P-value Age (mean±sd) (y) 68.5±9.2 68.7±11.0 0.925 Male gender (%) 33 (89.1) 35 (77.7) 0.241 Follow up duration 22.8 35.9 0.249 (mean±sd) (mon) TASC II classification C lesion (%) 18 (48.6) 12 (26.6) D lesion (%) 19 (51.3) 33 (73.3) Cormorbidity Smoking (%) 17 (47.2) 25 (55.5) 0.267 Hypertension (%) 27 (72.9) 24 (53.3) 0.068 Diabetes (%) 24 (64.8) 14 (31.1) 0.002 ESRD (%) 4 (10.8) 2 (4.4) 0.402 IHD (%) 9 (24.3) 5 (11.1) 0.114 Hyperlipidemia (%) 11 (29.7) 17 (37.7) 0.444 CVA (%) 6 (16.2) 5 (11.1) 0.500 CLI (%) 25 (67.5) 22 (48.8) 0.089 RV (%) 4.8±2.9 4.93±2.9 0.841 Distal runoff number 2.03±1.04 2.09±0.82 0.764 TASC II C 2.33±0.97 2.50±0.52 TASC II D 1.74±1.04 1.94±0.86 Pre-Tx ABI 0.56±0.18 0.38±0.25 0.014 TASC II C 0.63±0.11 0.52±0.14 TASC II D 0.41±0.23 0.32±0.27 Post-Tx ABI 0.82±0.25 0.85±0.59 0.872 TASC II C 0.92±0.13 0.71±0.39 TASC II D 0.69±0.33 0.89±0.65 PTA/S = percutaneous transluminal balloon angioplasty/stenting; BP = bypass surgery; TASC = trans atlantic inter-society consensus; ESRD = end stage renal disease; IHD = ischemic heart disease; CVA = cerebrovascular accident; CLI = critical limb ischemia; RV = resistance value; Tx = treatment; ABI = ankle-brachial index. CLI를보인경우가 47 하지였고, 치료군별로보면 CLI 를보인경우가 PTA/S-C군 9 하지, PTA/S-D군 16 하지, BP-C군 6 하지, BP-D군 16 하지였으며, 파행증만보였던환자들에서더높은일차개존율을보였다 (P=0.021). Modified runoff scoring system을이용한 resistance value에서 5 이하를보인환자가 40 하지로 6 이상을보인 42 하지에비해의미있게일차개존율이높게나왔으며 (P=0.020), distal runoff score가 2 3개인환자는 64 하지, 0 1개인환자는 18 하지였고 2개이상인환자들에서더좋은일차개존율을나타냈다 (P=0.049) (Table 2). (1) 혈관내치료군에서위험인자에따른일차개존율의차이 : 혈관내치료를받은 37 하지의각각의시술에대하여 Table 3에요약하여기술하였다. 스텐트삽입술을시행하지않은 4 하지는내막하박리혈관성형술과풍선확장술을함께시행하거나풍선확장술만시행한후 Table 2. The differences of primary patency rate in all patients according to risk factors Treatment indication Resistance value Distal runoff number Claudication Critical limb ischemia <5 6 0 1 2 3 n=82 35 47 40 42 18 64 24 months primary patency rate (%) 93.9 65.7 77.9 53.6 46.5 70.2 P-value 0.021 0.020 0.049 Table 3. The interventional procedures in percutaneous balloon angioplasty with or without stenting (PTA/S) group PTA/S-C PTA/S-D PTA/S-Total Balloon angioplasty 1 1 2 Stent insertion 0 2 2 Balloon angioplasty 15 13 28 +Stent insertion Subintimal angioplasty 1 1 2 +Balloon angioplasty Subintimal angioplasty 1 2 3 +Balloon angioplasty +Stent insertion Total 18 19 37 PTA/S = percutaneous transluminal balloon angioplasty/stenting. 혈관조영술에서원위부로의혈류가충분하다고판단되어스텐트삽입술없이시술을마쳤다. 대퇴-슬와동맥외에총장골동맥, 외장골동맥, 총대퇴동맥등의근위부병변에대해함께시술을했던경우가 14 하지, 대퇴- 슬와병변에만시술했던경우가 23 하지를나타내양군간에일차개존율의의미있는차이는보이지않았다 (P=0.364) (Table 4). 표재대퇴동맥에삽입한스텐트의길이는평균 7.55±1.71 cm (4 15 cm) 로나타났다. (2) 우회수술군에서위험인자에따른일차개존율의차이 : 우회수술을받은 45 하지중에서대퇴-슬와동맥우회술을시행한경우는 34 하지였고, 전경골동맥에문합한경우가 3 하지, 후경골동맥에문합한경우가 7 하지, 비골동맥에문합한경우가 1 하지였다. 문합부위의차이에따른일차개존율의비교를보면, 무릎상부에서문합한경우가 12 하지, 무릎하부가 33 하지로유의한차이는없었고, 이식편의종류에따라대복재정맥을사용한경우가 22 하지 ( 무릎상부문합 : 3 하지, 무릎하부문합 : 19 하지 ), polytetrafluoroethylene (PTFE) 을사용한경우가 23 하지 ( 무릎상부문합 : 9 하지, 무릎하부문

Sung Hwan Shin, et al:management of TASC II C & D Femoro-Popliteal Lesions 93 Fig. 1. The differences of primary patency rate between percutaneous balloon angioplasty/stenting and bypass surgery in TASC II C and D lesions. TASC = trans atlantic inter-society consensus; PTA/S = percutaneous transluminal balloon angioplasty/stenting; BP = bypass surgery. 합 : 14 하지 ) 로이식편에따른일차개존율의차이는없었다. 대복재정맥을사용한 22 하지에서대복재정맥의방향에따라 in situ로수술한경우가 18 하지, 역위대복재정맥이식편 (reverse) 으로수술한경우가 4 하지로나타났고대복재정맥의방향에따른일차개존율의차이는보이지않았다 (Table 5). 3) TASC II C, D군에서혈관내치료와우회수술간의일차개존율비교일차개존율은 PTA/S-C군에서 12개월에 82.4%, 24개월에 82.4% 를보였고, PTA/S-D군에서 12개월에 45.3%, 24개월에 45.3% 를보였으며, BP-C군에서의일차개존율은 12개월에 91.7%, 24개월에 73.3% 였고, BP-D군은 12개월에 77.1%, 24개월에 66.6% 였다. TASC II C군에서혈관내치료를시행한환자와우회수술을시행한환자들가운데일차개존율의유의한차이는보이지않았고 (P= 0.876), TASC II D군에서는우회수술군이혈관내치료군보다더높은일차개존율을나타냈다 (P=0.034) (Fig. 1). 4) TASC II C, D군에서혈관내치료와우회수술간의이차개존율비교이차개존율은 PTA/S-C군에서 12개월에 88.2%, 24개월에 88.2% 를보였고, PTA/S-D군에서 12개월에 54.7%, 24개월에 54.7% 를보였으며, BP-C군에서의이차개존율 은 12개월에 91.7%, 24개월에 73.3% 였고, BP-D군은 12 개월에 80.2%, 24개월에 73.3% 였다. PTA-C군과 BP-C군은이차개존율에서의미있는차이를보이지않았고 (P= 0.669), PTA-D군과 BP-D군역시차이가없었다 (P=0.077) (Fig. 2). 5) TASC II C, D군에서혈관내치료와우회수술간의하지구제율비교 TASC II C군에서 PTA/S-C군과 BP-C군의하지구제율은 PTA/S-C군에서유의하게더높게나왔고 (P=0.030), TASC II D군에서는 PTA/S-D군과 BP-D군간에통계적으로의미있는하지구제율의차이는보이지않았다 (P= 0.377) (Fig. 3). 6) 합병증및사망례혈관내치료를시행한경우시술후합병증에는혈관내막박리가 7예, 서혜부혈종이 1예, 전경골동맥폐색이 1예관찰되었고전경골동맥폐색이있던환자에서혈전용해술을시행하였으나우측 4, 5번째족지괴사를보여절단술을시행하였다 (Table 4). 수술후합병증은 8 예에서관찰되었는데심근경색증 3예, 뇌경색 1예, 폐렴 1예, 창상감염 2예, 문합부위출혈 1예였다 (Table 5). 사망례는 PTA/S군에서 2명, BP군에서 2명있었고담도계패혈증및심근경색증으로사망하였다.

94 대한혈관외과학회지 : 제 26 권제 2 호 2010 Fig. 2. The differences of secondary patency rate between percutaneous balloon angioplasty/stenting and bypass surgery in TASC II C and D lesions. TASC = trans atlantic inter-society consensus; PTA/S = percutaneous transluminal balloon angioplasty/stenting; BP = bypass surgery. Fig. 3. The differences of limb salvage rate between percutaneous balloon angioplasty/stenting and bypass surgery in TASC II C and D lesions. TASC = trans atlantic inter-society consensus; PTA/S = percutaneous transluminal balloon angioplasty/stenting; BP = bypass surgery.

Sung Hwan Shin, et al:management of TASC II C & D Femoro-Popliteal Lesions 95 Table 4. The differences of primary patency rate in angioplasty group according to risk factors Multiple therapy* Complication Yes No Yes No n=37 (%) 14 (37.8) 23 (62.2) 9 (24.3) 28 (75.7) 24 months primary patency rate (%) 69.2 59.8 55.6 66.2 P-value 0.364 0.688 *Multiple therapy was defined as combined procedures for femoral and iliac artery. Complication = Intimal dissection - 7 cases, Groin hematoma - 1 case, Arterial occlusion - 1 case. 고 하지의말초혈관폐색성질환은초기에간헐적파행의증상으로나타나지만심해지면휴식기통증까지나타나며하지의혈류가개선되지않는경우피부의궤양과조직괴사로인하여하지나족부의절단이라는심각한결과와함께동반된질환의악화로인해사망의위험도가높은질환이다. 치료는임상증상의호전과하지의절단을예방하는것을목적으로하며증상에따라운동요법, 약물요법, 혈관성형술과스텐트삽입술, 그리고혈관우회수술등으로나눌수있다 (4,6-8). 2007년발표된 TASC II 분류에따른치료권고사항을보면 TASC II A, B 병변에서는혈관내치료가우선적으로고려되며 TASC II C 병변에서는수술위험도와환자의동반질환, 술자의경험등을함께고려하여우회수술에서좋은결과를얻을수있다고하였고, TASC II D 병변에서는우회수술이좀더좋은개존율과하지구제율을기대할수있다고하였다 (2,4). Hynes 등 (9) 과 Sultan과 Hynes(10) 의연구에의하면 TASC II C, D 환자들을대상으로혈관성형술과우회수술을시행한결과환자의증상경감과치료비용, 5년개존율에있어혈관성형술이우회수술에비해떨어지지않는다는결과를보여주었으나, 최근 Alimi 등 (11) 의연구에따르면 TASC II 분류에따른각군의환자들에대해혈관성형술과우회수술의 3년일차개존율과이차개존율을비교한결과 TASC II C 병변에서는혈관성형술과우회수술이비슷한결과를나타냈지만 TASC II D 병변에서는우회수술군에서우수한개존율을보였다. Schermerhorn 등 (12) 은 TASC C 이상의병변에는스텐트시술이우회수술에비해불리하다고보고하였고, Surowiec 등 (8) 은 TASC A와 B에서는스텐트삽입술이우수한성적을보였으나, TASC C와 D에서는스텐트삽입술의개존율이낮아우회수술을권장한바있다. 본연구에따르 찰 Table 5. The differences of primary patency rate in bypass group according to risk factors Anastomosis level Graft type Complication* Above knee TASC II C TASC II D Below knee TASC II C TASC II D GSV TASC II C TASC II D PTFE TASC II C TASC II D Yes No n=45 (%) 12 (26.6) 1 (2.2) 11 (24.4) 33 (73.3) 11 (24.4) 22 (48.8) 22 (48.8) 5 (11.1) 17 (37.7) 23 (51.1) 7 (15.5) 16 (35.6) 8 (17.7) 37 (82.3) 24 months primary patency rate (%) 68.7 68.3 75.4 61.8 87.5 65.3 P-value 0.647 0.797 0.716 TASC = trans atlantic inter-society consensus; GSV = great saphenous vein; PTFE = polytetrafluoroethylene. *Complication = Myocardial infarction - 3 cases, Cerebral infarction - 1 case, Pneumonia - 1 case, Wound infection - 2 cases, Anastomosis site bleeding - 1 case. 면 TASC II C 병변에서 PTA/S군과 BP군간에일차개존율, 이차개존율에서유의한차이를보이지않았으나, TASC II D 병변에서는 BP군의일차개존율이 PTA/S군에비해의미있게높았다. 따라서 TASC II D 병변에서는현재우회수술이우선적으로고려되어야할것으로생각된다. 하지만, TASC II D 병변에서 CLI를보인경우가 PTA/S-D군에서 19 하지중 16 하지, BP-D군에서 33 하지중 16 하지로 PTA/S-D군에서더많아 CLI가 BP-D군보다 PTA/S-D군의개존율이낮게나온것에영향을줄수있는한계를가져더많은환자를대상으로한추가연구를통해개존율의비교가필요하다고판단된다. 본연구에서는 TASC II C군에서 PTA/S군의하지구제율이 BP군에비해높게나왔으며, TASC II D군에서는 PTA/S군과 BP군간에하지구제율의차이가없었는데이도대상환자가적었고추적관찰기간이짧았기때문이라판단된다. 최근에는중재시술과스텐트재질의발전으로스텐트내재협착이나혈전형성의비율이낮아수술의고위험군을가진경우 TASC II C, D 병변에서도스텐트시술이시도되고있다 (10,13). 그러나 15 cm 이상의긴병변의경우에는스텐트삽입술의장기개존율이매우낮기때문에우회수술을시행하는것이바람직하다고알려져

96 대한혈관외과학회지 : 제 26 권제 2 호 2010 있다 (14). 본연구의 TASC II C군에서는 PTA/S군과 BP 군간에일차및이차개존율에차이가없었으며, 따라서고령이거나심한동반질환을가진경우 TASC II C 병변에서 PTA/S를먼저시도하는것도고려해볼만한치료방침이라생각된다. TASC II 분류를포함하여병변의복잡성에의해 TASC II D 병변으로갈수록시술의실패율이증가하고일차개존율이낮아진다는것은일반적으로알려져있는사실로써 (4,8,14-17) DeRubertis 등 (18) 의연구에의하면 1,000예 (730명) 의서혜부하방의동맥병변에대해중재적혈관시술을시행했을때 TASC II D 병변 (332 하지 ) 의 24개월일차개존율이 55% 를보여 TASC II A,B,C 병변에비해의미있게일차개존율이낮았다. Distal runoff score에따른일차개존율의차이에있어 Clark 등 (19) 과 Ihnat 등 (20) 은 resistance value가높은환자들에서일차개존율의의미있는감소를보인다고하였고, 본연구에서도 resistance value가 6 이상으로높은환자들에서일차개존율이의미있게낮게나왔다. 일반적으로인조혈관의경우무릎상부문합이무릎하부문합보다성적이좋으며자가정맥을이용할때인조혈관을이용한경우보다더좋은개존율을기대할수있다고알려져있다. Klinkert 등 (21) 에의하면대복재정맥과 PTFE을이용한대퇴-슬와동맥의우회수술에서대복재정맥을이용했을때 5년일차개존율이 69% 로 PTFE를사용했을때의 49% 보다우수한일차개존율을보고한바있고, Plecha 등 (22) 은대복재정맥을사용할때 2년개존율이약 75% 로인조혈관에비해우수하다고하였다. 본연구에서는우회수술군에서이식편의종류와원위부문합부의위치에의한개존율의차이를보이지않았는데이는연구대상군이충분하지않았고추적관찰기간이짧은한계에기인하며향후많은환자들을대상으로한전향적인연구가필요할것으로생각된다. 결론 TASC II C, D 병변의치료에있어, TASC II D군에서우회수술을했을때혈관내치료를했을때보다더우수한개존율을보여일차적치료로우회수술을고려할수있을것으로판단된다. 그러나 TASC II C군에서는혈관내치료와우회수술간에통계적으로의미있는개존율의차이를보이지않아여러인자들을고려하여혈관내치료또는혈관우회수술의유무를결정해야할것으로생각된다. REFERENCES 1) Darling RC 3rd, Roddy SP, Chang BB, Paty PS, Kreienberg PB, Maharaj D, et al. Long-term results of revised infrainguinal arterial reconstructions. J Vasc Surg 2002;35: 773-778. 2) Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31: S1-S296. 3) Kedora J, Hohmann S, Garrett W, Munschaur C, Theune B, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg 2007;45:10-16. 4) Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45 (Suppl S):S5-S67. 5) Dosluoglu HH, Cherr GS, Lall P, Harris LM, Dryjski ML. Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease. J Vasc Surg 2008;48:1166-1174. 6) Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517-538. 7) Taylor LM Jr, Porter JM. Clinical and anatomic consideration for surgery in femoropopliteal disease and the result of surgery. Circulation (New York) 1991;83(2 suppl):i63-i69. 8) Surowiec SM, Davies MG, Eberly SW, Rhodes JM, Illig KA, Shortell CK, et al. Percutaneous angioplasty and stenting of the superficial femoral artery. J Vasc Surg 2005;41:269-278. 9) Hynes N, Akhtar Y, Manning B, Aremu M, Oiakhinan K, Courtney D, et al. Subintimal angioplasty as a primary modality in the management of critical limb ischemia: comparison to bypass grafting for aortoiliac and femoropopliteal occlusive disease. J Endovasc Ther 2004;11:460-471. 10) Sultan S, Hynes N. Five-year Irish trial of CLI patients with TASC II type C/D lesions undergoing subintimal angioplasty or bypass surgery based on plaque echolucency. J Endovasc Ther 2009;16:270-283. 11) Alimi YS, Hakam Z, Hartung O, Boufi M, Barthelemy P, Aissi K, et al. Efficacy of Viabahn in the treatment of severe superficial femoral artery lesions: which factors influence long-term patency? Eur J Vasc Endovasc Surg 2008;35: 346-352. 12) Schermerhorn ML, Cronenwett JL, Baldwin JC. Open surgical repair versus endovascular therapy for chronic lower-extremity occlusive disease. Annu Rev Med 2003;54:269-283. 13) Park KH. Endovascular treatment of iliac & femoral artery occlusive disease. J Korean Soc Vasc Surg 2008;24:72-75. 14) Matsi PJ, Manninen HI, Vanninen RL, Suhonen MT, Oksala I, Laakso M, et al. Femoropopliteal angioplasty in patients with claudication: primary and secondary patency in 140 limbs

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