대한내과학회지 : 제 72 권부록 2 호 2007 Angio-seal 사용후발생한가성동맥류를초음파유도하트롬빈주입으로치료한 1예 부산대학교의과대학내과학교실, 영상의학과교실 2 황기원 전국진 안성규 김경엽 김창원 2 홍택종 신영우 =Abstract= A case of ultrasound-guided thrombin injection therapy for pseudoaneurysm caused by the hemostatic puncture closure device angio-seal. Ki Won Hwang, M.D., Kook Jin Chun, M.D., Sung Gyu An, M.D., Kyung Yup Kim, M.D., Chang Won Kim, M.D. 2, Taek Jong Hong, M.D. and Young Woo Shin, M.D. Departments of Internal Medicine and Radiology 2, Pusan National University College of Medicine, Busan, Korea The Angio-seal closure device at femoral access sites is a quick, safe system that allows rapid healing of the vascular access site following performance of coronary angiography and interventional procedures. The occurrence of pseudoaneurysm after using Angio-seal is uncommon. Because of the possibility of surgical morbidity, ultrasound-guided thrombin injection therapy has recently been developed. We report here on our experience with an Angio-Seal associated pseudoaneurysm, which was successfully treated via ultrasound-guided thrombin injection. A 65-year-old patient received the Angio-seal after percutaneous coronary angiography through a right common femoral arterial puncture, and the patient developed shock and a pseudoaneurysm with hematoma at the peripuncture site. The ultrasound-guided therapy was performed and immediate thrombotic obliteration of the pseudoaneurysm occurred. Ultrasound-guided thrombin injection therapy may be considered for the initial treatment of Angio-Seal associated pseudoaneurysm.(korean J Med 72:S181-S185, 2007) Key Words : Angio-Seal, Pseudoaneurysm, Thrombin, Coronary angiography 서론대퇴동맥을이용한심장도관술, 말초동맥조영술과관상동맥촬영술은과거에비해많이증가하고있으며이와동반하여출혈, 가성동맥류, 하지허혈등과같은주요혈관합병증의빈도가증가하고있다. 최근개발된혈관폐쇄장치인안지오실 (Angio-seal, Diag Corp, St Jude Medical Co., St Paul, Minnentonka, Minnesota, U.S.A) 은천자동맥의도관제거시지혈을용이하게 하여조기보행을가능하게하여환자의불쾌감과입원기간을단축시키지만주요혈관합병증의발생률을줄이지는못하였다. 그러나대상환자의선택이나시술자의숙련정도에따라많은차이를보일수있다. 관상동맥촬영술후발생한가성동맥류의경우심장질환등의동반질환과고용량의항응고제사용으로인해수술및마취위험도가높아수술적치료가제한되어왔다. 수술이제한되어진경우혈관초음파검사를이용한압박요법이사용되어왔으나최근에혈관초음파검사를이용한 Received : 2006. 2. 27 Accepted : 2006. 6. 27 Correspondence to : Kook Jin Chun, M.D., Department of Internal Medicine Pusan National University College of Medicine, 1-10 Ami-dong, Seo-gu, Busan 602-739, Korea E-mail : hero0791@paran.com - S181 -
- 대한내과학회지 : 제 72 권부록 2 호 2007 - A B Figure 1. Transverse color Doppler ultrasonogram (A). This view shows typical swirling pattern of flow within the pseudoaneurysm lumen with blood flow into the pseudoaneurysm in one portion of the lumen and the blood flow out of the pseudoaneurysm in the other portion of the pseudoaneurysm. (B) A similar view showing the pseudoaneurysm neck (arrow) is demonstrated. 트롬빈 (thrombin) 직접주입요법이효과적이라고알려져있다. 본저자들은안지오실을사용한후에발생한가성동맥류를트롬빈직접주입요법을이용하여성공적으로치료하였기에문헌고찰과함께보고하는바이다. 증례환자 : 최 순, 여자 65세주소 : 흉통현병력 : 2005년 2월안정시 30분간지속되는흉통을주소로본원내원하여입원 3일째오른쪽대퇴동맥을통해 7 Fr. 의카테터를삽입하였다. 헤파린은관상동맥중재술직전 5,000 단위를정주하고이후시간당 1,000 단위를지속적으로정주하면서활성화응고시간 (activated clotting time) 을 250 300초로유지하였다. 관상동맥촬영술상좌전하행지중위부및우관동맥근위부및중위부에유의한협착소견보여좌전하행지중위부에풍선도자를이용하여전확장을시행한후스텐트를삽입하 였다. 시술후카테터를제거하고안지오실을사용하여지혈하였다. 안지오실은먼저기존의유도관을제거한후에운반관을위한유도초를삽입하였다. 여기에다시충전물이담긴운반관을유도초에삽입하고혈관내에유치한후장력을유지하면서운반관은밀고충전관은당겨서고정체와교원질충전물에의한천자혈관부위가폐쇄되도록하였다. 이런상태로 3 5분간유지한후에실을자르고운반관을제거하였다. 당시출혈이나혈종의소견은관찰되지않았다. 과거력 : 1978년고혈압및 1995년당뇨병으로진단받고약물치료중이며 1989년샘종성방패샘종으로갑상선절제술시행받았다. 환자는 1998년흉통으로본원내원하여안정형협심증으로약물치료시작하였다. 가족력 : 특이사항없음. 이학적소견 : 내원당시혈압 130/80 mmhg, 맥박 84회 / 분, 호흡수 20회 / 분, 체온 36 였다. 급성병색소견이었으며흉부및복부진찰상특이소견은없었다. 검사실소견 : 일반혈액검사상백혈구 5,800/mm 3 - S182 -
- 황기원외 6 인 : 가성동맥류를트롬빈주입으로치료한 1 예 - Figure 3. On 29th days of thrombin injection, a three dimensional reconstruction of the MR angiogram shows a normal common iliac artery bilaterally. A B Figure 2. Thrombin injection to the pseudoaneurysm. (A) Gray-scale ultrasound of the pseudoaneurysm shows the tip of the needle (arrow) positioned within the superficial aspect of the lumen and the echogenic thrombi (arrowheads) (B) Color Doppler image after injection of 1000 units of thrombin shows complete thrombosis of the pseudoaneurysm. ( 호중구 58.9%, 임파구 30.3%, 단핵구 9.5%, 호산구 1.0%, 호염기구 0.3%), 혈색소 11.3 g/dl 혈소판 229,000/mm 3, 적혈구침강속도 100 mm/hr, hscrp 0.05 mg/dl 이었다. 일반생화학검사상 AST/ALT 21/25 IU/L, alkaline phosphatase 182 IU/L, LDH 328 IU/L, 총단백 6.4 g/dl, 알부민 3.5 g/dl, BUN 17.5 mg/dl, creatinine 0.7 mg/dl 이었다. 치료및경과 : 관상동맥중재술후침상안정중혈압 80/50 mmhg, 혈색소 8.7 g/dl로감소되고오른쪽총장골동맥에혈종이관찰되어색도플러초음파를시행하였다. 2.46 1.80 cm 크기의저에코낭성병변이관찰되고내부에비정상적인왕복혈류운동을보이는소용돌이가관찰되어가성동맥류로진단하였다 ( 그림 1A, 1B). 관상동맥촬영술 3일째혈압은 90/60 mmhg로회복되었으나대퇴부의부종및통증이심해져 4일째색도플러초음파를다시시행하였다. 가성동맥류가커지는양상을보여가성동맥류입구를확인하고초음파유도하에경피적으로트롬빈 1000 units을주입하였다 ( 그림 2A, 2B). 트롬빈주입 2일에시행한추적초음파상가성동맥류에비정상혈류가소실되었으며대퇴부의부종감소하는양상을보였다. 트롬빈주입 29일째시행한자기공명영상과혈관촬영술에서총장골동맥에가성동맥류관찰되지않았으나 ( 그림 3) 감염성혈종관찰되어두차례의수술시행후외래추적관찰중이다. 고찰대퇴동맥을통한복잡하지않는관상동맥촬영술후천자혈관주위에발생하는합병증은 3 5%, 복잡한관 - S183 -
- 대한내과학회지 : 제 72 권부록 2 호 2007 - 상동맥중재술의경우 10 14% 로보고되고있다 1, 2). 혈종, 가성동맥류, 동정맥루등의천자혈관주위합병증은입원기간, 비용, 사망률을증가시킨다 3). 고식적용수압박법으로지혈한경우피포를제거하고이후완전히지혈한후에 8시간정도의절대안정이필요하여환자의불편이극심하였다. 관상동맥촬영술도중복잡한시술에의한큰피포의사용과아스피린, 헤파린, 혈소판당단백 IIb/IIIa 수용체차단제와같은항응고물질의사용이증가됨에따라출혈및혈종과같은주요혈관합병증이더욱증가하였다 4-7). 따라서천자동맥의도관제거시지혈을용이하게하고발생할수있는합병증을줄여주기위해다양한형태의기구들이개발되어사용되고있다. 현재까지가장인기있는혈관폐쇄기구로서안지오실은교원질충전물과흡수성중합고정체를사용한삽입형혈관폐쇄장치다. 안지오실의정착과정은두가지로나눌수있다. 우선은도자철선을넣고대퇴동맥에이미삽입되어있는피포를제거하고안지오실의유도를위한다른피포를삽입하는과정이다. 다음으로충전물이담긴운반관을피포내로삽입하고고정체를고정시킨후장력을유지하면서충전관을밀고피포와운반관을당겨피부표면에실을제거한다 8). 본원순환기내과에서 2003년 1월 1일부터 2003년 12 월 31일까지경피적관상동맥중재술후안지오실을사용한경험을보면 117명의환자에게사용하여반상출혈과같은경한출혈을포함하여 46명 (39.3%) 의환자에서출혈및혈종등의합병증이발생하였고, 수혈이필요한합병증은 8명이었으나가성동맥류의발생은없었다. 대규모의연구에서고식적용수압박법을이용한천자혈관지혈방법에비해안지오실을이용한경우출혈, 혈종, 가성동맥류등과같은주요혈관합병증의발생률이큰차이가없었으며, 천자혈관주위에발생하는합병증의경우에는시술자의숙련도, 대상환자의특징에따라많은차이를보인다 9-13). Warren 등 7) 은충전물이담긴운반관이완전하게피포내로삽입되지않은환자에서발생한가성동맥류를보고하였다. Gonze 등 14) 은 286명의환자에게안지오실을시술하여한명에서안지오실이대퇴동맥의가쪽벽에삽입되어발생한가성동맥류를경험하여보고하였다. 본증례의경우도가성동맥류의발생원인으로동맥내로완전하게피포가삽입되지않은상태로고정체가혈관내벽에서고정되지않고혈관벽내에서고정되어약해진벽으로가성동맥류가발생했 을가능성이많다. 관상동맥촬영술후천자혈관에발생하는가성동맥류의경우특별한치료없이자연적인혈전형성에의해폐쇄되거나크기가큰경우에조기수술이전통적인방법으로알려져있으나관상동맥질환과같은고위험인자를지닌경우수술이어려운경우가많아이런단점을극복하기위한많은중재술들이연구되어왔다. 1986년 Cope와 Zeit 15) 가투시하에서대퇴동맥의가성동맥류에트롬빈 (thrombin) 을주입하여성공적으로지혈한이후로 Liau 등 16) 이다섯명의가성동맥류환자를초음파유도하에서트롬빈을주입하여치료하였다. 최근수술이힘든고위험군환자에서발생한가성동맥류의경우초음파유도하에서트롬빈직접주입요법이사용되고있다. 트롬빈은프로트롬빈 (prothrombin) 의활성형 (active form) 으로비활성화섬유소원 (fibrinogen) 을섬유소로전환시켜혈전형성을활성화한다. 초음파유도하트롬빈주입법은성공률이높고가성동맥류내에혈전을유도하여지혈의시간이짧으며동통이적고헤파린을투여받고있는환자의경우에도안전하게치료가가능하다 17). 하지만안지오실을시술후원위부색전증이동반되거나혈관벽내남아있는안지오실이이물질반응을야기하여혈관벽의괴사를발생할가능성이높다. 따라서대부분은혈관폐쇄장치시술후발생한가성동맥류에서보존치료에반응하지않는경우조기수술을시행하였다. 최근에국내의경우 Park 등 18) 이안지오실시술후발생한연조직염과연관된가성동맥류를항생제투여와함께고식적인용수압박법으로치료하였으며 Closure S device 시술후발생한가성동맥류를트롬빈직접주입요법으로성공적으로치료하였다. 본증례의경우안지오실시술후발생한가성동맥류를초음파유도하에서트롬빈직접주입요법을통해성공적으로치료하였다. 결론적으로안지오실을이용한천자혈관에즉각적인조치를필요로하는합병증이발생할수있으므로이에대한세심한주위가요구되며고령이나수술의고위험군환자에서초음파유도하의트롬빈주입은대퇴동맥가성동맥류환자에서시도할만한간단하고안전한시술방법이다. 요약저자들은안지오실을사용한후에발생한가성동맥류를초음파유도하트롬빈직접주입요법을이용하여성 - S184 -
- 황기원외 6 인 : 가성동맥류를트롬빈주입으로치료한 1 예 - 공적으로치료한 1예를경험하였기에문헌고찰과함께보고하는바이다. 중심단어 : 안지오실, 가성동맥류, 트롬빈, 관상동맥촬영술 REFERENCES 1) Waksman R, King SB 3rd, Douglas JS, Shen Y, Ewing H, Mueller L, Ghazzal ZM, Weintraub WS. Predictors of groin complications after balloon and new-device coronary intervention. Am J Cardiol 75:886-889, 1995 2) Omoigui NA, Califf RM, Pieper K, Keeler G, O'Hanesian MA, Berdan LG, Mark DB, Talley JD, Topol EJ. Peripheral vascular complications in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I). J Am Coll Cardiol 26:922-930, 1995 3) Carere RG, Webb JG, Miyagishima R, Djurdev O, Ahmed T, Dodek A. Groin complications associated with collagen plug closure of femoral arterial puncture sites in anticoagulated patients. Cathet Cardiovasc Diagn 43:124-129, 1998 4) Moscucci M, Mansour KA, Kent KC, Kuntz RE, Senerchia C, Baim DS, Carrozza JP Jr. Peripheral vascular complications of directional coronary atherectomy and stenting: predictors, management, and outcome. Am J Cardiol 74:448-453, 1994 5) Spokojny AM, Sanborn TA. Management of the arterial puncture site. J Interv Cardiol 7:187-193, 1994 6) Muller DW, Shamir KJ, Ellis SG, Topol EJ. Peripheral vascular complications after conventional and complex percutaneous coronary interventional procedures. Am J Cardiol 69:63-68, 1992 7) Warren BS, Warren SG, Miller SD. Predictors of complications and learning curve using the Angio-Seal closure device following interventional and diagnostic catheterization. Catheter Cardiovasc Interv 48:162-166, 1999 8) Henry M, Amor M, Allaoui M, Tricoche O. A new access site management tool: the Angio-Seal hemostatic puncture closure device. J Endovasc Surg 2:289-296, 1995 9) Koreny M, Riedmuller E, Nikfardjam M, Siostrzonek P, Mullner M. Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis. JAMA 291:350-357, 2004 10) Seok JH, Park YH, Kim MK, Lee SH, Kim W, Hong GR, Park JS, Shin DG, Kim YJ, Shim BS. Efficacy and Complications of Angio-Seal Device in Patients Undergoing Coronary Angiography and Angioplasty. Korean Circ J 33:574-582, 2003 11) Kim YH, Gwon HC, Kim PH, Ahn SJ, Yu CW, Choi JH, Lee SC, Kim JS, Kim DK, Jun ES, Lee SH, Hong KP, Park JE, Seo JD. The efficacy and safety of angioseal compared to conventional manual compression after transfemoral percutaneous coronary intervention. Korean J Med 66:496-503, 2004 12) Ward SR, Casale P, Raymond R, Kussmaul WG 3rd, Simpfendorfer C. Efficacy and safety of a hemostatic puncture closure device with early ambulation after coronary angiography. Am J Cardiol 81:569-572, 1998 13) Silber S. Hemostasis success rates and local complications with collagen after femoral access for cardiac catheterization: analysis of 6007 published patients. Am Heart J 135:152-156, 1998 14) Gonze MD, Sternbergh WC 3rd, Salartash K, Money SR. Complications associated with percutaneous closure devices. Am J Surg 178:209-211, 1999 15) Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. Am J Roentgenol 147:383-387, 1986 16) Liau CS, Ho FM, Chen MF, Lee YT. Treatment of iatrogenic femoral artery pseudoaneurysm with percutaneous thrombin injection. J Vasc Surg 26:18-23, 1997 17) Middleton WD, Dasyam A, Teefey SA. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms. Ultrasound Q 21:3-17, 2005 18) Park Y, Roh HG, Choo SW, Lee SH, Shin SW, Do YS, Byun HS, Park KB, Jeon P. Prospective comparison of collagen plug (Angio-Seal) and suture-mediated (the Closer S) closure devices at femoral access sites. Korean J Radiol 6:248-255, 2005 - S185 -