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외국 진료를 못믿겠다고 방문했으나.. 드문 상장간막동맥박리에 대한 상의, 혈관외과 의뢰 - 동대문구 답십리, 교문동, 우리안애 우리안愛 내과

40대 중반 남자, 초진

4~5일전 복통으로 베트남 응급실

; 참을 수 없는 정도의 복통... 윗배/약간 왼쪽으로 치우쳐서.. 6시간 지속되었다.

방문시 6일이 지난 상태이며 복통은 없는 상태로

혈액검사 및 복부 CT 시행했는데 판독지 및 아래와 같은 사진을 가지고 방문

"베트남 병원을 믿지 못하겠다." 앞으로 외국의사 수입하면 어쩔건지?

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노란화살표는 찢어진 부위같고 공간이 생겨있다. 같은 쪽인 상장간막동맥 (SMA; superior mesenteric artery) 의 전벽이 두꺼워져 있다.

흔한 상황이 아니므로 추적 계획이나 자연경과를 알고 있는 혈관외과 진료 보도록 안내하였다.

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However it is rare for these branches to have dissection in the absence of main aortic trunk involvement. Among visceral arteries, superior mesenteric artery (SMA) is the commonest type of dissection when compared with other gastrointestinal arteries such as the splenic, hepatic, celiac and gastric arteries. However, isolated SMA dissection is believed to be rare. 대동맥의 침범없이 분지에만 박리가 있는 경우는 드물다. 그나마, 비장/간/위/복강동맥보다는 상장간막에 빈도가 많지만 대동맥 침범없이 상장간막동맥에 국한된 박리는 드물다고 생각된다. 흔하지 않기에 임상적 모습, 영상진단의 추구, 치료, 예후 및 결과가 자세히 연구되어 있지 않다.


It generally can have one of the four courses; cessation of SMA dissection with no long term sequelae, progressive involvement of the whole vessel, dissecting aneurysm joining the true lumen, or rupture of the vessel causing severe bleeding. 다음의 4가지 경과를 가질수 있다; 후유증 없이 박리의 중단, 진행하여 전체 혈관의 침범, 박리성 동맥류가 되어 혈관내부와 연결, 파열되어 심한 출혈


An increasing number of patients with SMA dissection who are hemodynamically stable are treated conservatively. 혈압등 안정적이면 많은 수의 환자들이 보존적 치료를 받고 있다. Along with anticoagulation therapy (heparin drip or warfarin), conservative management includes antiplatelets like cilostazol and ticlopidine, bowel rest and control of risk factors like hypertension. Anticoagulation does not revert or halt the progression of dissection but prevents thrombus formation and its distal embolization. It is recommended to have complete bowel rest and administer intravenous heparin until the abdominal pain settles. Oral anticoagulants and antiplatelet medications are continued until resolution of radiological images.

; 이런 투약은 베트남에서 입원시키거나 투약했어야 할텐데?

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Hemodynamically unstable patients having signs and symptoms of ischemia or those with radiological evidence of progression or worsening SMA dissection, such as formation of thrombus, narrowing or saccular aneurysm formation, should have urgent revascularization, as they are at high risk of rupture. The two main revascularization techniques are endovascular or surgical repair. A surgical procedure is inevitable in cases of bowel infarction or SMA rupture. The extent and type of surgery depends on the viability of gut, type of dissection and the reversibility of circulation. Sisteron and Viveville in 1975 performed the first SMA surgical revascularization using a saphenous vein graft. 허혈의 증상 혹은 영상의학적 박리가 진행하면 파열의 위험이 높기때문에 응급 혈관수술이 필요하다.

Endovascular management includes intralesional thrombolytic therapy, stent placement, embolotherapy and balloon angioplasty. Leung et al. first described percutaneous stent placement for SMA dissection. Endovascular technique is a minimally invasive procedure, prevents progression of dissection and provides instant relief from ischemia with shorter hospital stays.


Follow up

There are no available guidelines for the interval of follow-up and imaging studies for SMA dissection patients. More studies are needed to determine the long-term benefits of each of the different management modalities. In our review, the cumulative follow up for all studies ranged from 1 week to 7.5 years. This longest follow up was observed in a patient who was managed conservatively and there were no further SMA dissection episodes reported. The longest follow-up for endovascular treatment was 4.1 years, and 11 years for surgical procedure in 3 patients. We believe that repeat CT scans should be performed on follow up in all patients to monitor the progression/resolution of SMA dissection in cases of conservatively managed SMA dissection and to look for the patency of stenting in endovascularly managed cases. Similarly, CT scan, if performed on regular follow up, can give an idea about post-surgical long-term complications in SMA dissection patients. Our review showed that the interval of follow up and hence the duration of post management imaging varied widely among all studies. In a study by Sakamoto et al., a CT scan was performed weekly initially for the first month and then only twice or thrice over the span of years thereafter. 한 연구에서는 첫 한달은 1주일마다, 이후 수년에 걸쳐 단지 2~3번. We advocate that there should be evidence-based recommendations for regular follow up imaging for each treatment modality of SMA dissection.

; 추적 방문이나 영상검사 간격에 대한 진료지침은 없는 상태이다.

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CT 계속 찍어야 하나요? 주치의에게 물어봐야할 사항


We believe that physicians should follow the American Gastroenterological Association guidelines and should consider diagnostic work-up in an appropriate clinical setting for acute mesenteric ischemia in every patient with a history of unexplained abdominal pain for more than 2–3 hours.

; 혈관 허혈에 대한 복통은 빈도도 적고 구별하기가 어렵다고 생각되는데...

설명이 안되는 2~3시간 이상의 복통?

-- 꽤 아픈 복통이면서 (intractable pain) 신체검사상 압통이 없다면 (장의 궤사가 없는 상태)

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동대문구 답십리 우리안애, 우리안愛 내과, 건강검진 클리닉 내과 전문의 전병연



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