뇌혈관용 Guiding catheter와 Penumbra를 이용하여 시행한 흉·복부 및 다리혈관에 대한 기계적 혈전제거술

곽현욱(Hyun-Wook Kwak),최대연(Dae-Yeon Choi),임동욱(Dong-Wook Lim) 대한인터벤션영상기술학회 2010 대한인터벤션영상기술학회지 Vol.13 No.1

Purpose More than 12 sorts of medical tools for mechanical thrombolysis have been created since 1989. medical tools for thrombolysis, AngioJet, Oasis & Arrow-Trerotola device etc are currently used in domestic hospitals. manual aspiration for thrombolysis have been performed with 50cc syringe in the angio department of PNUYH. Mechanical thrombolysis for abdomen & lower extremity by guiding catheter & penumbra for cerebrovascular only was on trials. the trials are going to be presented as the case of successful study. Materials and methods Case1 60 years old female diagnosed as Arteriosclerosis obliterans received mechanical thrombolysis in March, 2010. 8 hundred thousand Urokinase had been infused to the patient using Multi-sideport catheter (Cook, Bloomington, USA) in advance. Blocked lesion ranged from abdominal aorta at lumbar level to iliac artery. The abdominal aorta was aspirated by Penumbra pump (Penumbra, Inc. Alameda, USA) connected with 6Fr Envoy guiding catheter (Cordis, Florida, USA) in the method of mechanical thrombolysis. On the other hand, iliac artery was aspirated by either guiding catheter with a pump or guiding catheter with 0.014in * 0.035in (cone) * 200㎝ Penumbra separator 041 (Penumbra, Inc. Alameda, USA). Thrombus in lower extremity flowing from abdominal aorta thrombolysis was also aspirated by guiding catheter with separator 041. Total blood loss was 370cc. 8 hundred thousand Urokinase was infused into Popliteal artery through Multi-sideport catheter. Case2 33years old male, diagnosed as thrombosis in Internal jugular vein and Innominate vein took the procedure in April, 2010. 1million Urokinase was infused at Internal Medicine. The blocked lesion ranged from subclavian vein via brachiocephalic vein to SVC. The thrombus was eliminated in the way of guiding pumping and guiding & separator pumping side by side using 6Fr Envoy guiding catheter connected with Penumbra pump. The total blood loss was 370㏄. Percutaneous Transluminal Angioplasty was performed in the stenosis lesion after the thrombolysis. Result Case1 It took approximately 1~2min for aspiration from abdominal aorta to iliac artery. During the aspiration however, some departed thrombus flowed to lower extremity vessel and then aspiration for femoral artery and thrombolytic therapy for popliteal artery were carried out to remove the thrombus. Next day, opening from abdominal aorta to dorsal artery of foot could be confirmed on angiography. Moreover complications such as blood spill out of vessels and recurrence of thrombus were not observed. Case2 Mechanical thrombolysis by guiding catheter and penumbra was successful. It took about 15min for aspiration. The opening vessel was confirmed and complications were not found. the procedure was finished and then Percutaneous Transluminal Angioplasty for remaining occlusion lesion would be followed up due to recoil. Discussion Through the medical trial above there are several value-judgements bellow that can be studied and verified continuously. First, the matter of usefulness for guiding catheter and penumbra pump or separator & pump. Second, the matter of possibility to solve vessel occlusion caused from DVT by guiding catheter and penumbra pump only Third, the study of possibility to eliminate thrombus occurred in femorofemoral bypass graft. Forth, the study of possibility to remove thrombus caused by Arteriovenous anastomosis site as the case of using general 4Fr or 5Fr catheter. Fifth, the study of using Urokinase which has severe complication of bleeding Sixth, the study for removing thrombus using Penumbra Reperfusion catheter and Separation instead of percutaneous transluminal angioplasty when the case of acute thrombus located in the area of Knee joint occurs. Nevertheless it has different problems that Penumbra system is for cerebrovascular only. Conclusion There are several problems in this procedure. that the mechanical thr

급성 허혈성 뇌졸중 환자의 기계적 혈전 제거술 후 조영제와 출혈혈액의 감별시 Dual energy의 유용성 평가

이상헌(Sang-Heon Lee),최대연(Dae-Yeon Choi),강헌효(Heon-Hyo Kang),강동원(Dong-Won Kang) 대한CT영상기술학회 2017 대한CT영상기술학회지 Vol.19 No.2

목적 : 본 연구는 급성 허혈성 뇌경색을 진단받고 혈관조영실에서 기계적 혈전제거술 후 Dual energy를 이용한 CT (DECT)에서 조영제와 출혈혈액의 감별을 통한 영상의 진단적 가치 및 선량을 Single energy CT (SECT)와 비교평가하여 검사의 유용성을 알아보고자 한다. 대상 및 방법 : 2016년 6월부터 2017년 1월까지 급성 허혈성 뇌졸중(acute ischemic stroke)을 진단받고 본원 혈관조영실에서 회수성스텐트를 이용한 뇌혈관내 기계적 혈전제거술(solitaire FR Stent를 이용한 IA thrombolysis, intracranial vessel thrombectomy using retrievable stent)을 시행한 환자 34명을 대상으로 하였다. 사용된 CT장비는 Somatom Definition Flash, Somatom Definition AS+(Siemens healthcare, Forchheim, Germany)이며 dual energy로 획득한 데이터를 3D-workstation (SyngoMMWP)에서 3가지 재료 분해 알고리즘(3-material decomposition algorithms)을 이용하여 가상 비 조영 영상(virtual non-contrast images, 이하 VNC)과 요오드 오버레이 영상(iodine overlay images, iodine overlay maps, IOM)을 재구성하여 수행하였다. 조영제와 출혈혈액의 감별을 통한 영상의 진단적 가치를 비교하기 위해서 DECT는 혼합 영상(mixed images)과 VNC, IOM을 제공하고, SECT는 DECT검사 후 획득한 혼합영상만으로 대체하여 두경부 판독전문의 1명이 각 각 평가하였다. 선량비교는 DECT는 시술 직후, SECT는 추적검사(f/u)시 DLP (dose length product)를 평가하였다. 측정된 결과는 대응표본 t검정(paired sample t-test, SPSS 버전 20)을 이용하여 분석하였으며, 통계학적 유의수준은 0.05 미만으로 하였다. 결과 : 총 대상자 34명 중 79.4% (27/34)는 일시적인 혈액 뇌 장벽 붕괴로 인한 조영증강(transient BBB disruption), 17.6% (6/34)는 비정상적인 합병증의 증거 없음(no evidence of unusual complication), 2.9% (1/34)는 출혈 전환(hemorrhagic transformation)이었다. 구별의 정확한 확인을 위해서 24시간 전후 추적검사를 시행하였다. 조영제와 출혈혈액의 감별을 통한 영상의 진단적 가치를 very good (4점)~poor (1점)으로 평가한 결과 DECT는 평균 3.29점, SECT는 2.18점으로 DECT가 SECT보다 영상의 진단적 가치가 높은 것으로 나타났다(p <0.001). DECT의 DLP는 평균 822.39 mGy·cm, SECT는 827.00 mGy·cm이었으며 통계적으로 유의한 차이는 없었다(p =0.448). 결론 : 급성 허혈성 뇌졸중환자에서 기계적 혈전제거술 후 DECT는 SECT와 비교하여 동일한 선량으로 요오드화 조영제와 출혈을 구별할 수 있으며, 많은 진단적 정보를 제공함으로서 유용한 검사라 사료된다. Purpose : The purpose of this study is to determine the usability of examination on CT using dual energy (DECT) compared to single energy (SECT) by evaluating diagnostic value of image and radiation dose through distinguishing contrast media from hemorrhage after the mechanical thrombectomy in the patients diagnosed with acute ischemic stroke. Subjects and Methods : The subjects of this study were 34 patients who were diagnosed with acute ischemic stroke and underwent the intracranial vessel thrombectomy using retrievable stent in the angiography laboratory of Pusan National University, Yangsan Hospital from June 2016 to January 2017. The CT system used in this study are Somatom Definition Flash and Somatom Definition AS+(Siemens Health care, Forchheim, Germany) and the evaluation of distinguishing contrast media from hemorrhage was performed by reconstructing virtual non-contrast images (VNC) and iodine overlay images (IOM) of the acquired data from dual energy using 3-material decomposition algorithms in the 3D-workstation (Syngo MMWP). DLPs (Dose length product) of dual energy CT and single energy CT were compared for the evaluation of radiation dose. Results were analyzed using the paired sample t-test, SPSS version 20 and the statistical significance level was less than 0.05. Results : 79.4% of the subjects (27/34) showed enhancement by transient blood-brain barrier disruption (BBB disruption), 17.6% (6/34) showed no evidence of unusual complication, and 2.9% (1/34) had hemorrhagic transformation. For the rigorous validation, 24 follow-up examinations were performed. According to the diagnostic value of image which evaluated by the distinction ability contrast media from hemorrhage as very good (4 points) ~ poor (1 point), DECT showed higher diagnostic value than SECT by scoring 3.29 points (DECT) and 2.18 points (SECT) in averagd (p <0.001). DLP of DECT and SECT were 822.39 and 827.00 mGy cm, resepectively and showed no significant difference (p=0.448). Conclusion : Compared with SECT, DECT is considered the useful examination that can distinguish iodine contrast media from hemorrhage with same dose after the mechanical thrombectomy in the patients with acute ischemic stroke and provides much more diagnostic information.