심부정맥혈전증 검사시 Tracker 기법의 유용성 평가

이윤상(Yun Sang Lee),이준협(Jun Hyub Lee),남진현(Jin Hyun Nam),박성수(Seong Soo Park),이경숙(Kyung Sook Lee),이장범(Jang Beom Lee),최태규(Tae Kyu Choi) 대한CT영상기술학회 2009 대한CT영상기술학회지 Vol.11 No.1

Purpose In deep vein thrombosis test, 180sec latency test, one of existing test methods, has less accuracy of diagnosis because the image of venous thrombosis may be shown differently according to the status of cardiac output, artery occlusion, etc. thus in the present study, an attempt was made to look into the clinical availability of the new test method of performing test at the peak of a time-threshold curve for popliteal veins by using tracker method of multi-detector computed tomography. Materials and methods A retrospective study was made for total 32 patients consisting of 16 patients who took the existing test and 16 patients who took the new test among patients who visited the hospital between May and July 2008 and took deep vein thrombosis test. Using tracker method of the new test method, threshold was set to be high for popliteal veins, and tracking was started 50 seconds after beginning angiography, and when the tracking time curve started to bend downward from the peak of the threshold, test was done together with injection of a cell line in order to reduce arteriography. After test, comparison on the images between existing test method and new one was made and they went through statistical analysis, and based on these, the availability of those images in deep vein thrombosis test was evaluated. Results For thrombosis parts of total 32 patients who took deep vein thrombosis diagnosis, in existing test group, they were mainly found in large blood vessels of the pelvis and abdomen by order of iliac veins, femoral veins, and popliteal veins, while in new test group, they were equally found in popliteal veins, iliac veins, and femoral veins. This result implies that the existing test method has limitations in identifying the extent of the proximal portion for venous thrombosis according to the patient’s cardiac output, artery occlusion, etc. On the other hand, it was pointed out that the new test method showed a highly contrast-enhanced image of arteries, but the quality of image of venous phase could be raised by injection of a cell line. As a result of analysis by statistics of independent sample t-test between existing test group and new test group, a significance level was shown to be(p<0.05)p=0.008, which indicates there was statistically significant difference. Conclusion In the new test method, significantly high incidence of thrombosis was found with development of multi detector computed tomography, thus the new test method is deemed as more useful method in terms of objectivity and accuracy of diagnosis, compared to the existing test method. It is concluded that more prospective studies are required to be made for establishment of protocol with many cases.

심부정맥혈전증의 병인 분석

이제환 ( Lee Je Hwan ),박선양 ( Park Seon Yang ),계경채 ( Gye Gyeong Chae ),정철원 ( Jeong Cheol Won ),신현춘 ( Sin Hyeon Chun ),이진학 ( Lee Jin Hag ),양성현 ( Yang Seong Hyeon ),김병국 ( Kim Byeong Gug ),김노경 ( Kim No Gyeon 대한내과학회 1993 대한내과학회지 Vol.44 No.3

연구배경 : 심부정맥혈전증은 체내 지혈혈전계의 불균형에 의해 발생하며 최근 혈전증 연구의 발달로 심부정맥혈전증의 여러 가지 선행 인자들이 알려져 있다. 국내에서도 상당수의 심부정맥혈전증이 발생하고 있으나 그임상상 및 발생요인 등의 병인론에 관해서는 잘 알려져 있지 않다. 이에 저자들은 서울대학교병원 내과에서 심부정맥혈전증(종양색전은 제외)으로 진단받은 85예의 환자를 대상으로 임상적 선행 인자를 조사하였으며 동시에 혈액응고학적 선행 인자에 대한 검사를 실시하였다. 방법 : 혈전증의 임상상 및 혈전증의 임상적 선행 인자를 알기 위하여 대상 환자들의 병록지와 심부정맥혈전증의 진단시 시행된 방사선학적 검사를 검토하였으며, 혈전증을 유발할 수 있는 혈액응고학적 선행인자의 분석을 위하여는 항 cardiolipin 항체, C 단백, S 단백, antithtombin Ⅲ, tissue-type plasminogen activator 및 plasminogen activator inhibitor type 1, 혈장 섬유소 용해능을 검사하였다. 결과 : 1) 대상 환자 85예중 남자 40예, 여자 45예로 남녀비는 1 : 1.13 이었고, 나이는 15세에서 77세로 중앙치는 47세였다. 대상 환자의 연령별 분포는 40대가 21예 (24.7%)로 가장 많았고, 50대가 19예(22.4%), 30대가 16예 (18.8%), 20대가 10예(11.7%), 60대가 9예 (10.6%), 70세 이상이 6예(7.1%)였고, 20세 미만도 4예 (4.7%) 있었다. 2) 심부정맥 혈전증의 발생 부위로는 장단지(calf)의 정맥에 국한된 경우가 7예(8.2%), 근위부쪽으로 슬와정맥(popliteal vein)까지 관여된 경우가 7예(8.2%), 장골 정맥(femoral vein)까지 관여된 경우가 12예 (14.1%), 대퇴 정맥(iliac vein)까지 관여된 경우가 37예(43.5%)로 하지가 전체 대상 환자의 74.1%인 63예였으며, 하대 정맥과 신 정맥이 관여된 경우가 8예(9.4%), 문 맥(portal vein)이 관여된 경우가 8예(9.4%)로 복강내 정맥 혈전증이 16예(18.8%) 있었다. 그외 상지의 정맥이 관여된 경우가 4예(4.7%), 상대 정맥 혈전증이 1예(1.2%)있었으며, 심부정맥혈전증의 증거가 없는 폐동맥 색전증이 1예(1.2%)있었다. 전체 대상 환자중 29예(34.1%)에서 폐동맥 색전증이 합병하였다. 3) 심부정맥혈전증의 임상적 선행 인자로는 고령(60세 이상)이 15예(17.0%), 악성종양 13예(15.3%), 혈전증의 과거력이 있는 경우가 11예(12.9%), 수술후 상태가 9예(10.6%), immobilization이 7예(8.2%), 고지질혈증 5예(5.9%), 비만증 4예(4.7%), 혈류의 정체 4예(4.7%), 신증후군 3예(3.5%), 당뇨병 3예(3.5%), Behcet씨 병 2예(2.4%), 여성호르몬제 복용 2예(2.4%) 등이었으며, 특별한 임상적 위험인자가 발견되지 않은 경우가 25예(29.4%)였다. 4) 심부정맥혈전증의 혈액응고학적 선행 인자로는 항 cardiolipin 항체가 양성인 경우, C 단백의 기능적 활성도나 유리형 S 단백의 항원량이 정상의 60% 미만인 경우, antithrombin Ⅲ의 기능적 활성도가 정상의 70%미만인 경우, t-PA값이 정상치보다 낮거나 PAI-1 값이 정상치보다 높은 경우, 그리고 섬유소 용해능이 정상치 보다 낮은 경우 등을 생각하였는데, 항 cardiolipin 항체양성이 7예(19.4%), C 단백의 기능적 활성도가 정상의 60% 미만인 경우가 3예(16.7%), S단백(free form)의 항원량이 정상의 60% 미만인 경우가 3예(10.7%), antithtombin Ⅲ의 기능적 활성도가 정상의 70% 미만인 경우가 2예(5.9%), t-PA가 정상치보다 낮은 경우가 5예(22.7%), PAI-1이 정상치보다 높은 경우가 10예(29.4%), 섬유소 용해능 검사가 정상치보다 낮게 나온 경우가 14예(42.4%) 있었다. 결론 : 한국인에서의 심부정맥혈전증의 중요한 임상적 선행원인으로는 고령, 악성종양, 혈전증의 과거력, 수술후 상태, 기동장애였고, 혈전증과 관련된 혈액응고학적 검사의 이상소견으로는 PAI-1의 증가와 t-PA의 감소, 항 cardiolipin 항체 양성이 흔히 관찰되었다. Background : The formation of deep vein thrombosis reflects a balance between the effects of thrombogenic stimuli and a series of protective mechanisms. Substantial progress has been made in the last several decades in identifying hereditary and acquired risk factors predisposing to deep vein trombosis. Even so, a large number of patients still have no identifiable underlying cause for recurrent venous thrombosis. Elucidation of specific predisposing factor (s) is required for proper management of thrombosis. For the Korean patients, these factors have not been well characterized. Methods : We analyzed clinical profiles of the patients with venous thromboembolism and investigated the laboratory abnormalities known to be associated with increased risk of thrombosis. Results : 1) The male-female ratio was 1 : 1. 13 and age distribution showed 24.7% in fifth decade, 22.4% in sixth, 18.8% in fourth, 11.7% in third, 10.6% in seventh, 7.1% over 70 years old, and 4.7% under 20 years. 2) The thromboses were most commonly located in lower extremities (74.1%), and intraabdominal thromboses were 16 cases (18.8%), thromboses of upper extremities 4 cases (4.7%), superior vena cave thrombosis 1 case (1.2%) and pulmonary embolism without evidence of deep vein thrombosis 1 case (1.2%). Thirty-four percent of the cases were diagnosed as having pulmonary embolism. 3) The clinical risk factors for venous thromboembolism were old age(17.0%), malignancy (15.3%), prior history of venous thromboembolism (12.9%), postoperative state (10.6%), immobilization (8.2%), hyperlipidemia (5.9%), systemic lupus erythemato년 (4.7%), obesity (4.7%), stasis (4.7%), nephrotic syndrome (3.5%), diabetes mellitus (3.5%), Behcet`s disease (2.4%), estrogen (2.4%). Twenty-nine percent of the cases had no indentifiable clinical risk factors. 4) The laboratory abnormalities associated with venous thromboembolism were increase of anticardiolipin antibody (19.4%), decrese of protein C activity (16.7%), decrease of protein S (free form) antigenicity (10.7%), decrease of antithrombin Ⅲ activity (5.9%), decrease of tissue-type plasminogen activator (t-PA) (22.7%), increase of plasminogen activator inhibitor type 1 (PAI-1) (29.4%) and decrease of fibrinolytic activity (42.4%). Conclusion : Clinical and laboratory risk factors have been determined in 85 patients with deep vein thrombosis and/or pulmonary embolism in Korea. Major clinical risk factors for venous thromboembolism included old age, malignancy, prior history, postoperative state and immobilization. Among the laboratory abnormalities associated with venous thromboembolism, increase of PAI-1 and/of decrease of t-PA, and increase of anticardiolipin antibody were most frequently observed.

Endovascular Treatment for Iliac Vein Compression Syndrome: a Comparison between the Presence and Absence of Secondary Thrombosis

Wen-Sheng Lou,Jian-Ping Gu,Xu He,Liang Chen,Hao-Bo Su,Guo-Ping Chen,Jing-Hua Song,Tao Wang 대한영상의학회 2009 Korean Journal of Radiology Vol.10 No.2

Objective: To evaluate the value of early identification and endovascular treatment of iliac vein compression syndrome (IVCS), with or without deep vein thrombosis (DVT). Materials and Methods: Three groups of patients, IVCS without DVT (group 1, n = 39), IVCS with fresh thrombosis (group 2, n = 52) and IVCS with non-fresh thrombosis (group 3, n = 34) were detected by Doppler ultrasonography, magnetic resonance venography, computed tomography or venography. The fresh venous thrombosis were treated by aspiration and thrombectomy, whereas the iliac vein compression per se were treated with a self-expandable stent. In cases with fresh thrombus, the inferior vena cava filter was inserted before the thrombosis suction, mechanical thrombus ablation, percutaneous transluminal angioplasty, stenting or transcatheter thrombolysis. Results: Stenting was performed in 111 patients (38 of 39 group 1 patients and 73 of 86 group 2 or 3 patients). The stenting was tried in one of group 1 and in three of group 2 or 3 patients only to fail. The initial patency rates were 95% (group 1), 89% (group 2) and 65% (group 3), respectively and were significantly different (p = 0.001). Further, the six month patency rates were 93% (group 1), 83% (group 2) and 50% (group 3), respectively, and were similarly significantly different (p = 0.001). Both the initial and six month patency rates in the IVCS patients (without thrombosis or with fresh thrombosis), were significantly greater than the patency rates of IVCS patients with non-fresh thrombosis. Conclusion: From the cases examined, the study suggests that endovascular treatment of IVCS, with or without thrombosis, is effective. Objective: To evaluate the value of early identification and endovascular treatment of iliac vein compression syndrome (IVCS), with or without deep vein thrombosis (DVT). Materials and Methods: Three groups of patients, IVCS without DVT (group 1, n = 39), IVCS with fresh thrombosis (group 2, n = 52) and IVCS with non-fresh thrombosis (group 3, n = 34) were detected by Doppler ultrasonography, magnetic resonance venography, computed tomography or venography. The fresh venous thrombosis were treated by aspiration and thrombectomy, whereas the iliac vein compression per se were treated with a self-expandable stent. In cases with fresh thrombus, the inferior vena cava filter was inserted before the thrombosis suction, mechanical thrombus ablation, percutaneous transluminal angioplasty, stenting or transcatheter thrombolysis. Results: Stenting was performed in 111 patients (38 of 39 group 1 patients and 73 of 86 group 2 or 3 patients). The stenting was tried in one of group 1 and in three of group 2 or 3 patients only to fail. The initial patency rates were 95% (group 1), 89% (group 2) and 65% (group 3), respectively and were significantly different (p = 0.001). Further, the six month patency rates were 93% (group 1), 83% (group 2) and 50% (group 3), respectively, and were similarly significantly different (p = 0.001). Both the initial and six month patency rates in the IVCS patients (without thrombosis or with fresh thrombosis), were significantly greater than the patency rates of IVCS patients with non-fresh thrombosis. Conclusion: From the cases examined, the study suggests that endovascular treatment of IVCS, with or without thrombosis, is effective.

May-Thurner 증후군과 동반된 하지 심부정맥혈전환자에서 혈전제거술과 스텐트삽입술

전용선,조정수,윤용한,백완기,김광호,김정택,김영삼 대한흉부외과학회 2009 Journal of Chest Surgery (J Chest Surg) Vol.42 No.6

배경: May-Thurner 증후군은 좌측장골정맥이 우측장골동맥에 의해 눌리어 정맥 환류장해에 의해 혈전증을 일으키는 것을 말한다. 저자들은 심부 정맥혈전중의 치료를 위해 시행한 혈전 제거-용해술 및 스탠트 삽입술의 결과를 분석하고자 한다. 대상 및 방법: May-Thurner 증후군과 동반된 하지 심부정맥혈전증으로 진단받고 좌측 장골정맥에 스탠트를 삽입한 34명(평균연령 64.6±13.7세, 여자 25 (74%)명)을 대상으로 하였다. 시술은 흡인성 혈전제거와 혈전용해 후 분지성 협착이 있는 곳에 Wall stent를 삽입하고 풍선 확장을 하였다. Multi side hole 카테타를 혈전이 있는 부위에 위치시키고 Urokinase를 시간당 8만에서 12만 International Unit을 1일 또는 2일 동안 주입하였다. 시술 중 폐동맥혈전색전증을 방지 하기 위하여 대부분 환자에서 시술 전 일시적 하대정맥 여과기(IVC Filter)를 삽입하였다. 퇴원 후 3개월간 경구용 와파린을 투여 하였으며 퇴원 전과 퇴원 후 6개월에 Multi Detector Computerized Tomography (MDCT) 혈관촬영을 이용하여 혈전의 유무를 판단하였다. 결과: 시술 48시간 이내 부종과 동통이 완전하게 소실된 환자가 2 (6%)명이었으며 증상의 완화가 있는 환자가 28 (82%)명, 증상의 호전이 없는 환자가 4 (12%)명이었다. 퇴원 시 MDCT혈관촬영에서 9 (26%)명에서 혈전없음, 21 (62%)명에서 부분 혈전, 그리고 4명(12%)에서 폐쇄소견을 보였다. 퇴원 6개월 후에 2명을 제외한 32명이 추적 MDCT혈관촬영을 하였는데 23 (72%)명에서 혈전없음을 9 (26%)명에서는 부분혈전이 관찰 되었다. 평균 5.6개월 관찰기간 동안 2 (6%)명에서 심부정맥혈전이 재발되어 재입원하였으며 하지 부종과 통증을 동반한 혈전 후 증후군은 9예(26%)에서 발생하였다. 결론: May-Thurner 증후군과 동반된 하지 심부정맥혈전환자에서 심부정맥혈전의 제거와 혈전용해술과 함께 시술된 스탠트 삽입은 효과적인 치료 방법으로 생각된다. Background: Compression of the left common iliac vein by the overriding common iliac artery is frequently combined with acute deep vein thrombosis in patients with May-Thurner Syndrome. We evaluate the results of treatment with thrombolysis and thrombectomy followed by stenting in 34 patients with May-Thurner Syndrome combined with lower extremity deep venous thrombosis. Material and Method: The authors retrospectively reviewed the records of 34 patients (mean age: 65±14 year old) who had undergone stent insertion for acute deep vein thrombosis that was caused by May-Thurner syndrome. After thrombectomy and thrombolysis, insertion of a wall stent and balloon angioplasty were performed to relieve the compression of the left common iliac vein. Urokinase at a rate of 80,000 to 120,000 U/hour was infused into the thrombosed vein via a multi-side hole thrombolysis catheter. A retrieval inferior vena cava (IVC) filter was placed to protect against pulmonary embolism in 30 patients (88%). Oral anticoagulation with warfarin was maintained for 3 months, and follow-up Multi Detector Computerized Tomography (MDCT) angiography was done at the date of the patients’ hospital discharge and at the 6 months follow-up. Result: The symptoms of deep venous thrombosis disappeared in two patients (4%), and there was clinical improvement within 48 hours in twenty eight patients (82%), but there was no improvement in four patients (8%). The MDCT angiography at discharge showed no thrombus in 9 patients (26%) and partial thrombus in 21 (62%), whereas the follow-up MDCT at 6.4±5.5 months (32 patients) revealed no thrombus in 23 patients (72%), and partial thrombus in 9 patients (26%). Two patients (6%) had recurrence of DVT, so they underwent retreatment. Conclusion: Stent insertion with catheter-directed thrombolysis and thrombectomy is an effective treatment for May-Thurner syndrome combined with acute deep vein thrombosis in the lower extremity.

심부정맥혈전증을 동반한 신세포암

김정현,백성현,곽철,강정윤,김현회,이상은,이종욱 大韓泌尿器科學會 2001 Korean Journal of Urology Vol.42 No.12

종설 : 비전형적 부위에 발생하는 정맥혈전의 치료

방수미 ( Soo Mee Bang ) 대한내과학회 2014 대한내과학회지 Vol.86 No.1

Venous thrombosis in atypical locations means thrombosis of upper extremity deep vein, cerebral venous sinus, splanchnic vein including portal, hepatic, mesenteric and splenic vein, renal vein, ovarian vein and retinal vein. This thrombosis rarely occurred and could be affected by the involved organ when compared to the incidence and cause of deep vein thrombosis in lower extremity with or without pulmonary embolism. There is a limitation to perform a large-scaled randomized trial for these rare conditions, and several recommendations based on results of small-sized studies and observational registries are available now. Therefore, we need multi-department and international collaboration to test the efficacy and safety of anticoagulation including new oral anticoagulants in the treatment of venous thrombosis in atypical locations. (Korean J Med 2014;86:20-25)

Case Reports : Upper-extremity deep venous thrombosis in a patient with systemic lupus erythematosus without antiphopholipid antibody

( Hui Jung Kim ),( Kang Suk Ko ),( Sang Bae Park ),( Hyeong Il Kim ),( Yang Tong Cho ),( Woong Ji Kim ),( Byung Jun Jeon ),( Hye Min Yu ),( Min Ju Song ),( Yun Kyung Hong ),( Wan Hee Yoo ) 전북대학교 의과학연구소 2007 全北醫大論文集 Vol.31 No.2

Vascular thrombosis in the venous or arterial system is quite common in systemic lupus erythematosus(SLE), especially in patients who have active disease with vasculitis and antiphospholipid antibodies(aPL). These thrombotic events usually developed on deep veins of the lower extremities and very rarely occur on the upper extremities. The upper extremity deep vein thrombosis(UEDVT) is a relatively rare disease, constituting about 2% of all cases of deep venous thrombosis, and usually occurs axially and subclavian vein. Here, we report an unusual case of brachial and basilica vein thrombosis in a 34-yr-old woman with SLE after taking oral contraceptives for 3months before the onset of upper-extremity deep vein thrombosis(UEDVT). Venous Doppler ultrasonography and CT images showed thrombosis and thrombophlebeitis of the brachial and basilica vein of the left arm. Thrombophilia work-up including IgM and IgG anticardiolipin antibodies, lupus anticoagulant were negative. Protein C, Protein S, and antithrombin 3 levels were within normal range. The patient was started anticoagulation therapy and oral contraceptives were discontinued. After that, she was asymptomatic and she had been treated with aspirin 100mg/day.

증례 : 순환기; 고도비만 남성에서 발생한 상지 심부정맥혈전증과 폐동맥색전증

정현연 ( Hyun Yon Jung ),한아름 ( A Rum Han ),김희준 ( Hee Jun Kim ),박재현 ( Jae Hyun Park ),김선우 ( Sun Woo Kim ),김희준 ( Hee Jun Kim ),이남호 ( Nam Ho Lee ) 대한내과학회 2014 대한내과학회지 Vol.86 No.4

심부정맥혈전증은 폐동맥색전증의 주된 선행 질환이고폐동맥색전증은 발생 시 환자에게 치명적일 수 있으므로 심부정맥혈전증의 올바른 진단과 치료는 임상적으로 매우 중요하다. 대부분의 심부정맥혈전증은 하지에서 발생하나 약10%에서는 상지에서 발생하는 것으로 알려져 있으며 상지심부정맥혈전증은 최근 중심정맥관의 사용이 증가하고 영구심장박동기 이식이나 제세동기 삽입 등과 같은 중심정맥으로접근하는 시술이 늘어나면서 과거보다 유병률이 증가하는추세이다. 따라서 저자들은 고도비만 남성에서 상지 심부정맥혈전증과 폐동맥색전증이 발생한 예를 경험하였기에 보고하는 바이다. Deep vein thrombosis is a predisposing condition for pulmonary embolism, which can be fatal. Usually, deep vein thrombosis is found in the lower extremities, but it can also occur in the upper extremities. The prevalence of upper extremity deep vein thrombo-sis appears to be increasing, particularly due to the increased use of indwelling central venous catheters. Pulmonary embolism is present in up to one-third of patients with upper extremity deep vein thrombosis. Upper extremity deep vein thrombosis is an in-creasingly important clinical entity, with the potential for considerable morbidity. Here, we report a case of upper extremity deep vein thrombosis and pulmonary embolism in a severely obese man who was successfully treated with anticoagulants. (Korean JMed 2014;86:478-483)

C형 및 S형 단백 결핍에 의한 하지 심부 정맥혈전증

김향경,조용필,이덕희,안재홍,장혁재,김지수,김용호,한명식 대한혈관외과학회 2002 Vascular Specialist International Vol.18 No.2

Purpose: Protein C and S deficiencies are frequently described as causes of the hypercoagulable states. The aim of this study was to evaluate the clinical features and prognosis of deep venous thrombosis associated with protein C and/or S deficiencies and to determine an adequate treatment modality for such cases. Method: A total of consecutive 42 patients with deep venous thrombosis of the lower extremity were seen in our hospital between September 2000 and August 2002. Hypercoagulability studies were done before systemic anticoagulation therapy, and the diagnosis of protein C and/or S deficiencies was confirmed if antigenic protein C and/or S levels were less than 60%. Result: Seven patients (16.7%) were diagnosed with deep venous thrombosis associated with protein C and/or S deficiencies. Of these, 5 patients with acute iliofemoral deep venous thrombosis were treated with catheter-directed thrombolysis therapy, and 2 with systemic anticoagulation therapy. There were no major complications or clinically detectable pulmonary emboli. Conclusion: Protein C and/or S deficiencies are one of the common causes of deep venous thrombosis. Considering that patients with deep venous thrombosis and protein C and/or S deficiencies should be treated with life-long anticoagulation for the prevention of recurrence, patients presenting with deep venous thrombosis without evidence of other risk factors should be evaluated for hypercoagulable states.

Incidence and Clinical Significance of Deep Vein Thrombosis after Cementless Total Hip Replacement in Korean Patient Population

Kim, Young-Hoo,Suh, Jin-Suck,Kim, Jee-Yeon Yonsei University, College of Medicine 1987 Yonsei medical journal Vol.28 No.2