급성하지허혈을 동반한 양측 슬와동맥류 환자에서 Peroneal Artery에 대한 후접근법 치험

전희재,윤명희 대한혈관외과학회 2012 Vascular Specialist International Vol.28 No.4

A 71-year-old male patient presented with both popliteal mass and calf claudication for 6 years. He had abruptly developed acute pain in both legs and pale skin color after interpersonal conflict. A preoperative computed tomography angiogram checked in another university hospital showed thrombosed popliteal aneurysms with acute leg ischemia in both legs. The left popliteal aneurysm was exposed with a medial approach. A thrombectomy and bypass from the proximal popliteal artery to the distal popliteal artery was done. Unfortunately the leg ischemia did not improve and below knee amputation was necessary. After transfer to Haeundae Paik Hospital, the right popliteal aneurysm was exposed with a posterior approach. After an aneurysmectomy and popliteal-peroneal bypass with peroneal endarterectomy, the leg ischemia completely resolved. He was discharged without complications. Eighteen months has passed since this operation and the patient’s graft still has good patency. In the posterior approach to popliteal aneurysm, we found it possible to exposure vessels extensively including the popliteal aneurysm and it is easy to expose the distal artery. So we highly recommend the posterior approach for large popliteal aneurysm and distal artery bypass.

Lower extremity CTA 검사의 화질 향상과 환자의 피폭선량 감소를 위한 새로운 프로토콜 개발에 대한 연구

전찬일(Chan-il Jeon),박준철(Jun-Cheol Park),이성현(Seong-Hyeon Lee),박계연(Gye-Yeon Park) 대한CT영상기술학회 2017 대한CT영상기술학회지 Vol.19 No.2

목적 : 본 연구는 lower extremity CTA 검사 후 하지혈관의 하부 (tibial artery)와 발목 혈관(dosalis pedis plnta artery)들이 조영되지 않는 검사결과가 종종 발생하여, bolus tracker와 ROI 위치를 기존검사의 위치인 abdominal aorta에서 knee joint 레벨로 tracker 이동 위치하고 검사하는 새로운 프로토콜 개발을 통해, 환자 마다 각기 다른 하지혈관의 조영제 순환의 시간차가 어느 정도인지 분석하고, 환자의 재검사에 의한 피폭선량 증가를 줄이고, 단일 스캔으로 전체하지 혈관을 도출하여 2D영상과 3D 재구성 이미지 질 향상을 위해 이와 같은 연구를 하게 되었다. 대상 및 방법 : 2016년 1월부터 2017년 2월 까지 본원에서 lower ext. CTA 검사한 120명의 남녀 환자를 대상으로 자료를 수집 분석하였다. 장비별 조건은 Brilliance 64 120 kVp, 250 mAs, pitch 0.64이고, Aquilion one 120 kVp, sure exp3D, pitch 0.861이었으며, Somatom CARE kV, CARE mA, pitch 1.2였고, 조영제는 flow rate 5.0, total volume 140m l + normal saline 30 ml 추가로 auto injector를 통해 주입하였다. 우선, 프로토콜 변경 전 검사한 그룹을 A그룹, 후를 B,C,D그룹으로 나눠 각각 30건 자료 수집 및 검사 후 비교 분석하였다. 프로토콜 변경 전 A그룹은, 필립스 BR64 장비에서 복부대동맥에 ROI를 위치하여 threshold limit를 HU 200 검사한 자료를 수집하였고, 프로토콜 변경 후 검사한 B, C 그룹은, 도시바사의 Aquilion one (320)과 Seimens 사의 Definition AS (64) 두 장비 모두 patella 위쪽 2~3cm 정도에 politeal artery에 ROI를 위치하여 threshold HU 250 으로 검사하였다. 세 장비 모두 bolus 기법을 이용하여 검사한 후 자료를 분석하였다. D그룹은, Aquilion one 장비에서 HU값 변화에 따른 2D&3D 이미지 질을 비교 분석하기 위해 HU 300으로 변경하여 추가 검사한 후 B그룹과 비교 분석하였다. A,B,C,D 그룹의 조영제 주입 후 threshold limit time 값을 측정하여 환자마다 얼마나 차이가 나는지 분석하였으며, abdominal aorta, both politeal artery, both dosalispedis & planta artery 5곳의 ROI의 평균값을 측정하여 비교하였고, A그룹과 B,C,D그룹간의 재검사율과, DLP 값을 비교 분석하였다. 3D재구성에는 Voxar 3D Enterprise 프로그램을 이용하였으며, 데이터 분석에서 SPSS (version 18)를 사용하였다. 결과 : 첫째로, bolus 기법을 사용한 A그룹과B,C그룹의, tracker 위치 변화에 따른 threshold limmt time HU 250의 지연 시간을 비교 했을 때, A 그룹 BR64가 최소, 최대, 평균값이, 13 sec, 20 sec, 15.5 sec, B 그룹 Aquilion one은 20 sec, 71 sec, 33 sec, C 그룹 Somatom는 19 sec, 45 sec 27.5 sec 정도 소요되었다. 또, 각 장비별 혈관의 평균 HU를 비교 분석해 보면, 각각 레벨에서 측정한 혈관별로 aorta, politeal artery, dosalis pedis&plata artery 3부위로 나눠서 분석한 평균 HU값이, A그룹은 위쪽혈관부터, 442.5, 372.5, 151.1이었고, B그룹은 417.2, 511.7, 189.2이었고, C 그룹은 598.5, 550.2, 329.3이었으며, D 그룹은 481.8, 465.5, 240.7으로 분석되었다. 그리고, B,C, D그룹 검사 후 영상 2D axial & 3D 재구성 영상에 대한 판독을 전문의 2인에게 의뢰하였고, 판독 결과는 판독의ⅠⅡ 모두, 2D & 3D 판독 결과 모두 5점 만점에 4.1~4.2점 이상의 양호, 우수로 나왔으며, 그리고 장비 중에는 Somatom 장비에서 검사한 C그룹의 결과가, 2D & 3D 판독 결과 가장 우수한 것을 나타났다. 장비별 DLP의 평균값은, BR64 장비가 평균 1562.9 mGy·cm, Somatom 은 895.6 mGy·cm, AQUILLION 이752.4 mGy·cm로 1 phase 검사의 선량적 측면에서는 Philips BR64 장비가 타 장비에 비해 2배 이상 높게 나타났다. tracker 위치 변경 후 실시한 검사에서는 Aquilion one과 Somatom 장비 모두 재검사율은 0 %로 줄었으며, 프로토콜 변경 전 후 재검사율 및 하부 이중시기(2 phase)검사율을 비교하면, 변경 전엔 검사건 수 40건을 기준으로, 9.5 %, 48 %정도였는데 변경 후엔 재검사율과 하부혈관에 대한 이중시기(2 phase) 검사율 , Aquilion one % 와 Somatom 0 %, Aquilion one 10 %, Somatom 0 %로 줄어 들었다. 결과적으로, 재검사 뿐만 아니라 불필요했던 이중검사를 하지 않음으로서 환자의 선량 감소 효과를 얻을 수 있었다. 결론 : Lower extremity CTA 검사 시 새로 개발한 프로토콜 적용 즉, tracker와 ROI를 politeal artery 위쪽 2~3 cm에 설정하고, 적정한 threshold limit HU 설정,적정한 table pitch를 적용한다면, 불필요한 재검사 및 이중시기 검사를 줄일 수 있었고, 환자의 피폭선량 감소효과와 환자의 보다 적정한 조영증강 영상을 얻을 수 있었으며,또 3D 영상의 질 또한 향상시킬 수 있을 것을로 사료된다. Purpose : Examine results such as tibial artery and dorsalis pedis & plantar artery were not caught in contrast enhancement when testing lower extremity CTA ; because the old patients had arteriosclerosis, DM, claudication, medial calcification, which are diversity of blood circulation. Patients exposure is to be decreased after re-examination and the quality of reconstruction image of 2D and 3D is to be improved by changing the method that tested bolus tracker site on abdominal aorta, and placed then on the knee joint level to examine contrast enhancement manually. This study aims to acquire adequate contrast enhancement and dose reduction by changing the tracker’s spot into popliteal artery level. Materials and Methods : The resources were collected from January in 2016 to February in 2017, with 120 CTA patients of male and female. Brilliance 64 s conditions is 120 kVp, 250 mAs, and pitch 0.681. Aquilion one is 120 kVp, sure exp3D and pitch 0.861. Somatom is CARE kV, CARE mA and pitch 1.2. Also the injection flow rate is 5.0 ml/s and total volume is 140 ml with 30 ml normal saline. First, we divided 4 groups for comparison and analysis : Group A was an independent group before changing the protocol, and Group B, C, and D were dependent groups. Group A was tested with threshold limit of HU 200 using Brilliance 64 with ROI on abdominal artery. The other three groups were tested with threshold limit of HU 250 using Aquilion one and Definition AS with ROI on popliteal artery. Especially, group D was leveled at HU 300 to compare with the group B, and it was intended for analyzing the image quality with the variation of HU value. After injecting contrast, we assessed the average of 5 ROI that is, abdominal aorta, both politeal artery, both dorsalis pedis & plantar artery, to examine the differences of threshold limit time among patients. Then, the value of DLP and the portion of re-examination between group A and group B and D. We use Voxar 3D Enterprise program for 3D re-construction and SPSS version 18 for analysis. Results : First, we compared threshold limit time among group A, B, and C. It took 13s (min.), 20s (max.), and 15.5s (average) in group A. It took 20s (min.), 71s (max.), and 33s (average) in group B. In group C, it took 19s (min.), 45s (max.), and 27.5s (average). The average HU of abdoman aorta, politeal artery, dorsalis pedis & plantar artery in four groups are as follows: Starting from upper blood vessel, group A had 442.5, 372.5, and 151.1 HU. Group B had 417.2, 511.2, and 189.2 HU. Group C had 598.5, 550.2, and 329.3 HU. Finally, group D had 481.8, 465.5, and 240.7 HU. In case of Aquilion one, we consulted radiologist to evaluate the re-examined images of group D for comparison with group B and C. The results are follows : Group A scored 3 out of 5. Group B got 3 points except one case in 3D re-construction. Among the equipments, Somatom showed best score. The average DLP of equipments was 1562.9 mSv cm for Brilliance 64, 895.6 mGy cm for Somatom, and 752.4 mGy cm for Aquilion one. In the case of exposure, Brilliance 64(Philips) rated highest in 1 phase test. After changing tracker, the re-examination portion of Aquilion one and Somatom decreased to 0%. The reexamination portion and extra section exposure was 9.5% and 48 %, respectively, in 40 cases before changing the protocol. Due to the protocol changes, patient dose reduced up to 37% by reducing unnecessary testing and retesting. Conclusion : This study expects that dose reduction and appropriate contrast enhancement images will be acquired without unnecessary retesting, once the tracker is on popliteal artery as lower extremity CT angiography is examined. Also it suggests that we have better quality in 3D.

Popliteal Artery Occlusion in Total Hip Arthroplasty : A case report and review of the literature

Won, Ye-Yeon,Kim, Hyoung-Won,Chung, Kyung-Il 아주대학교 의과학연구소 1998 아주의학 Vol.3 No.2

Vascular injury is a serious but rare complication of hip arthroplasty procedures. Most of vascular complications reported in the literature occurred in the vessels around hip joint and femoral artery. To date, no report on popliteal artery' occlusion during or after total hip arthroplasty has been published. The present authors have observed one case of popliteal artery occlusion after total hip arthroplasty. We suspect that the cause of this occlusion was an excessive maneuvering of limb during operation and, subsequently atheromatous plaque fracture induced thrombosis in popliteal artery. An angiographic embolectomy was performed using a catheter, and circulation of the limb recovered. In order to reduce the risk of vascular complications in the total hip arthroplasty procedure, we recommend a thorough evaluation of lower extremity circulation in risky patients. When a vascular insult is suspected either during or soon after the procedure, a vascular consultation with arteriography including popliteal artery should be obtained urgently. A delayed treatment could result in a deleterious outcome.

관절경적 후방십자인대 재건술 후 발생된 슬와동맥 가성동맥류 -1예 보고-

김영진 ( Yeung Jin Kim ),양정환 ( Jung Hwan Yang ),채수욱 ( Soo Uk Chae ),이지완 ( Ji Wan Lee ) 대한스포츠의학회 2011 대한스포츠의학회지 Vol.29 No.1

The pseudoaneurysm of the popliteal artery following an arthroscopic posterior cruciate ligament reconstruction is rare. We present a case of the delayed pseudoaneurysm of the popliteal artery after arthroscopic posterior cruciate ligament reconstruction. Open excision of the pseudoaneurysm and pin-point repair were done. Retrospectively reviewing the case, we found that the relation of the popliteal artery and posterior cruciate ligament on preoperative magnetic resonance images can predict the complication of pseudoaneurysm of the popliteal artery.

슬와동맥 포착증후군 : 13예 13 Cases

이정훈,이태승,정인목,하종원,정중기,정진욱,박재형,김상준 대한혈관외과학회 2003 Vascular Specialist International Vol.19 No.2

비복근 기시부의 해부학적 기형에 의한 양측성 슬와 동맥 포착 증후군

박희곤 ( Hee Gon Park ),윤성현 ( Sung Hyun Yun ),김성진 ( Sung Jin Kim ) 대한스포츠의학회 2013 대한스포츠의학회지 Vol.31 No.1

Popliteal artery entrapment syndrome can result from abnormal branching patterns of the popliteal artery or the anatomically abnormal placement of nearby muscles and tendons leading to a sustained compression of the popliteal artery. This compression leads to chronic capillary damage and early arteriosclerosis and embolism that can lead to distal ischemia. Thus early treatment is required to prevent harm to the lower limb. This is a rare congenital disease that mostly affects young adults, usually presenting with intermittent claudication of the leg, coldness and edema. A case where a 16-year-old female presented with pain and coldness in the lower right limb that started 1 year ago will be discussed. In this case, magnetic resonance imaging and arterial angiography lead to a diagnosis of popliteal artery entrapment resulting from an abnormal origin of the medial head of Gastrocnemius.

Loss of Distal Femur Combined with Popliteal Artery Occlusion: Reconstructive Arthroplasty Using Modular Segmental Endoprosthesis: A Case Report

강신택,황찬하,김보현,성병윤 대한의학회 2009 Journal of Korean medical science Vol.24 No.2

Severe injury to the knee and the surrounding area is frequently associated with injury to ligaments of the knee joint and structures in the popliteal fossa. This case involved a popliteal artery occlusion, severe bone loss of distal femur, loss of collateral ligaments, and extensor mechanism destruction of the knee. Initially, prompt recognition and correction of associated popliteal artery injury are important for good results after treatment. After successful revascularization, treatment for severe bone loss of distal femur and injury of the knee joint must be followed. We treated this case by delayed reconstruction using modular segmental endoprosthesis after revascularization of the popliteal artery. This allowed early ambulation. At 36 months after surgery, the patient had good circulation of the lower limb and was ambulating independently.

슬와낭종의 슬와동맥 압박으로 유발된 간헐적 파행증

최성진,권민관,배수야,김동환,최정윤,이지혜,변영섭 순천향대학교 순천향의학연구소 2015 Journal of Soonchunhyang Medical Science Vol.21 No.2

Peripheral arterial disease is caused by atherosclerosis in the arteries causing an insufficient blood flow to the muscles and tissues. Peripheral arterial disease in the lower limbs is the main cause of intermittent claudication. Less commonly, the etiology of intermittent claudication can be extrinsic to vascular structures such as arterial aneurysm, arterial dissection, embolism, popliteal entrapment syndrome, and adventitial cystic disease. A 69-year-old man was referred to Sanggye Paik Hospital because of intermittent claudication. He had a history of diabetes mellitus and dyslipidemia and he was current smoker. His right ankle brachial index is 0.74. Lower extremity artery computed tomography scan was performed and it revealed the right popliteal cyst compressing the right popliteal artery. We performed the arthroscopic cyst drainage and after the procedure, intermittent claudication resolved completely.

오금동맥의 낭성혈관외막질환 -1증례 보고-

강수민,정경천,지제근 대한병리학회 1993 Journal of Pathology and Translational Medicine Vol.27 No.4

관절경 수술 후 발생한 슬와동맥 손상의 외과적 치료 −2예 보고−

이길수,류세민,조성준,조병렬,이봉기 대한흉부외과학회 2008 Journal of Chest Surgery (J Chest Surg) Vol.41 No.6

The indications and applications of arthroscopic surgery for the knee joint have increased with the development in surgical techniques and the improvement of arthroscopic equipment. The use of arthroscopic surgery has led to a significant decrease in morbidity for the patient with intra-articular abnormalities, in terms of both the diagnosis and the surgical treatments. Even though arthroscopy is a minimally invasive technique with relatively low morbidity, it is not without risk of complications, of which neurovascular complications are among the most serious and devastating. Here we report on 2 cases of popliteal artery injury during arthroscopic knee surgery and its specific diagnosis and treatment.