- • - ^ ^ • c m L U U LAM SANG
D i l u TRj BENH MACH MAU PHCTC TAP BANG CAN THIEP N 6 | M A C H PHOI HOfP PHAU THlJAT (HYBRID)
Doan Quoc Hinig*, Nguyen Duy Thang* Nguyin HuTu Udc*
Pham QuocDat^ Le Thanh Dung*, Nguyin Lan Hieu**
*Benh vien Viet Dire " B e n h vien Dai hoc Y Ha Npi
DAT VAN D^
Benh ly mach mau tai Viet Nam ndi chung va raien Bac noi rieng frong nhung nam gan day dien bien theo xu hudng tang dan ve sd lugng b^nh nhan cung nhu muc dp phflc tap efla benh. Nguyen nhan la tudi thp trung binh tang cung nhu thay ddi che dp dinh dudng eua benh nhan dan tdi ty le benh mach mau ngay cang tang. Cac benh mach mau phflc tap xuit hien dang la thach thuc vdi cac bac sT lara sang ea ve ngoai khoa eflng nhu can thiep tim mach. Vdi nhung benh nhan eo benh mach man phflc tap, tudi cao, nhieu vi tri tdn thuang, viec ap dung cac phuong phap kinh diln nhu phiu thuat don thuin hoae can thiep dan thuin se khdng mang lai hieu qua tot do phlu thuat tai nhilu vi tri cung mdt liic fren benh nhan gia ylu se anli hudng nang ne den sflc khde benh nhan, viec can thiep mach raau fren nhilu vi fri eung mot lue khong phai luc nao cung thye hien dugc, mat khac la ganh nang kinh t l ldn cho benh nhan va bao hiem y tl. Xu hudng fren thi gidi hien nay la ap dung phdi hgp phiu thuat va can thiep fren mgt benh nhan frong rapt tiii (hybrid) nhim Iam giam dp khd ciia phau thuaV can thiep.
giam chi phi y tl va giam tac dpng co hai fren
sflc khde benh nhan. Tai Benh vien Hflu nghi Viet Dflc, vdi sy giiip dd cua cac chuyen gia nude ngoai cung nhu kip can thiep mach mau, chflng toi da ap dung Hybrid phau thuat, can thiep frong cung mpt thi tien cac benh nhan cd benh ly mach mau kho dieu fri neu chi sfl dung phau thuat hoac can thiep don thuan vdi ket qua ban dau tuang ddi kha quan. Nghien cflu nay danh gia ket qua cua ap dung hybrid frong dieu fri benh mach mau nham nit ra ket luan ve chi dinh, lya chpn benh nhan, uu nhuge diem, ket qua, kha nang iing dung va phat trien.
DOI TUgTNG VA PHl/aNG PHAP
Benh mach mau phuc tap bao gdm tdn thuang mach mau tai cac vj fri mach quan frgng va khd dieu tri (Vi du quai dgng mach ehu, DM chfl ngyc doan xuong) hoac tdn thuang mach mau nhieu vi tri fren cung mdt benh nhan.
Nghien euu hdi eflu dya fren ho sa cua tit ca BN mach mau da ap dung phoi hgp phau thuat- ean thiep npi mach tai Benh vien Viet Dflc tfl 1/2011 tdi 11/2013. Cac phiu tiiuat- thu thuat dugc thye hien tai phong ml hoac
34 I TAP CHl TIM M^CH HQC Vl£T NAM - S<5 65.2014
N G H I £ N Cliu LAM SAI
^
tai phong can thiep mach - khoa dien quang Benh vien Viet Dire, vdi su tham gia cua phau thuat vien mach mau, chuyen gia Phap, bac si can thiep Benh vien Viet Diic va Benh vien Dai hoc Y Ha Ndi. Can thiep ndi mach co the dupc thuc hien trudc, sau hoac ddng thdi vdi can thiep phau thuat. Benh ly mach d cac vi tri khac nhau: Quai DM chu, DM chu bung, DM chau chimg, chau ngoai, DM chi dudi. Loai trir benh mach mau tai tim, phdi, chan thuang, vet thucmg mach mau, tai bien do thiy thudc.
cac tham dd ttudc md gdm lam sang, sinh hoa, chuc nang gan than, ddng mau, dien tim, sieu am tim, sieu am doppler mach, chup cat ldp vi tmh, chup DM, MRI. Tiln su benh phdi hpp va ylu td nguy co (hiit thudc la, thudc lao, dai thao dudng, tang huyet ap, md mau), tien su phau thuat dupc ghi nhan chi tilt. Chi dinh can thiep phiu thuat hay ndi mach theo hudng din ciia Chau Au va My. Dien bien trong qua
trinh phiu thuat/thu thuat, ket qua, bien chiing dupc thdng ke, phan tich, so sanh tir dd dua ra cac nhan xet ve chi dinh va kit qua cila hybrid, dl xuat y kiln thich hpp.
KET QUA
Trong thdi gian tir thang 1/2011 tdi thang 11/2013, cd 11 benh nhan CO benh mach mau phiic tap hdi dii cac chi tieu nghien ciiu dugt phan bd nhu sau: nam 11 (ty le 100%); tuSi thip nhit 64, cao nhit 79, trung binh 70,6 tudi. Chiing tdi chia cac benh nhan lam hai nhdm: nhdm 1 gdm cac BN cd benh ly ciia quai DM chu va DM chii xudng; nhdm II glm cac BN cd tdn thuang nhilu ting cua macli mau chu bymg, chau, diii chung, diii ndng va khoeo ttong benh ly mach mau ngoai bien.
Bang 1 Phdn bd benh nhdn co ldn thucmg quai DMC vd DMC nguc (n~3)
Can thilp hybrid
Dau nguc Phinh hinh tiji cua quai DMC
Phau thu^t bac cau DM canh chung P-T; dit Stentgraft quaiDMCvaDMC xuong (bit nguyen iiy ciia DM canh chung T)
Nam
73t« Dau nglic Phinh hinh tiii ciia quai DMC
Phau thuat bac cau DM chii len vao DM canh hai ben; dat stentgraft quai DMC va DMC xu6ng (bit nguyen uy ciia DM duoi don T)
Dau nguc Loc DMC 3tu6ng type B (Stanford) v5 vao tdioang mang phdi trai
Phlu thu^t b ^ c3u DM canh chung ^ P-T; Can thiep dat Stentgraft quai DMC va DMC xudng (bit nguyen iiy cua DM canh chung T)
TAP CHt TIM MACH HQC V1$T NAM - SO 65.20141 *
-•^^jrnewi 1,0U LAM SANG
Bang 2 Phdn bd benh nhdn co benh ly mgch mau ngogi bien (n=8)
T T
4
5
6
7
8
9
10
11 Gioi
Nain69t
Nam 64t
Nam65t
Nam67t
Nam 73t
Nam64t
Nam 741
Nam 761**
Chi djnh
Thilu mau g / d m chan T/
£)a mo bac cau dui khoeo T b ^ g mach nhan t ^
Thieu mau g/d IV 2 chan
Thieu mau csqj tinh chan P/ Da m6 bic c5u diai khoeoP
Dau bung/ BN da m6 bung ' lan do viem phiic mac RT va dinh ru^t
Thieu m^u g/d III chan T, g/d II chan P
Thieu mau g/d II chan P/
Da bic cau dtii khoeo 2 ben
Thieu mau g/d IV chan T, g/d n chan P
Thiiu mau giai doan III hai chan
T h n t m g t o n
Hep mifog noi dau tren va dau duoi ciia cau noi diii khoeo
Hep tic DM chau chung, chau ngoai P, Hep DM chau ngoai T, tic DM diii nong T
Huyet khoi gay tic mach nhan tao ; Hep mieng noi dau xa
Phong DM chii bung duoi than - chau goc ben P (DM chau goc P phong 3cm)
Hep tac DM chau ngoai, tic nga ba diii chung 2 ben
Huyet khoi gay tic mach nhan tao diii khoeo ben P, h?p DM chay sau, tac DM chay truac va DM mac
Hep DM chau gdc P, tic DM chau chung va chau ngoai T, tic DM diii nong P, hep DM dui nongT
Tic DM chau g6c P, hep DM chau g6c T, tac Dm diii nong hai ben
Can thiep hybrid
Phau thuat lam lai mieng noi dau gan; nong mieng noi dau xa
Nong DM chau ngoai T, phlu thuat bac cau diii-diii T-P (mach nhan tao)
Phau thuat mu mach nhan tao lay huyet khoi; nong mieng noi dau xa
Dat stentgraft cho DM chu chau P (Unilateral); Phau thuat bac cau diii-dCii P-T (mach nhan tao)
Nong va stent Dm chau ngoai ben T, nong DM dtii nong phia duoi thuong ton; Phlu thuat boc noi mac tao hinh nga ba DM dui T
Phlu thu|t md mach nhan tao lay huyet khoi; can thiep nong mach ngoai vi bing bong
Nong va stent DM chau goc P, Phau thugt boc noi mac DM diii chung trai va bic ciu diii dui P-T (mach nhan tao). Nong DM diii nongT
Can thiep nong va dat stent DM chau goc T, phlu thuat bic cau diii diii trai - phai
g 3. Kit qua cua hybrid (N=11 BN)
Ton t h u o n g
Quai DMC (n-3) DM chu chau (n=l) C^u n6! diii khoeo (n-3)
DM chau diii (n=4)
Cai thien trifu chiing
2/3 I/l 3;3 4/4
Tir vong 1/3 0/1 0/3 0/4
That b^i/bien chirng l/3»
0/1 0/3 1 ' 4 "
T y l e thanh cong %
67 100 100 75
36 I TAP CHl TIM MACH HOC VI$T NAM - S(5 65.2014
N O H I 6 W T : P U L A M SAN
• Benh nhan can thiep sd 2 trong nhdm can thiep vao quai DMC sau hybrid cd bien chiing nhdi mau ca tim phai dat stent mach vanh, dieu tri sau dd suy tim, viem phdi nang, nhiem trimg huyet va hi vong trong benh canh suy da tang, khdng cd bien chimg trong qua trinh lam hybrid, kiem tra sau hybrid khdng cd tai bien ve ky thuat nhu cliay mau, di lech stentgraft.
** Benh nhan can thiep sd 11 sau hybrid 8 ngay xuat hien dau lai 2 chan, sieu am va chup kiem tra cd tac DM chau gdc phai tren vi tri dat stent, da dupc xii ly bang bac cau nach diii trai vdi ket qua tdt.
BAN L U A N
Ljch sir phSt trien can thiep npi mach va Hybrid phau thuSt - can thiep
Nam 1964, Charles Theodore Dotter va cdng su la ngudi diu tien tiln hanh nong dpng mach diii ndng bang bong tren mot benh nhan nii 82 tudi thieu mau giai doan IV chan do tic DM diii ndng vdi kit qua rit tdt, dng cung la nguiri dua ra nhiing khai niem diu tien vl dung cu can thiep nhu bdng nong DM (Balloon catheter), guidewire. gia da trong long mach (stent). Ong dupc coi la cha de cua nganh can diiep[4]. Nam 1973, Porter JM bao cao trudng hpp lam sang diu tien phdi hpp giOa phiu thuat (bic ciu diii khoeo) va can thiep (nong DM bing bdng) vdi kit qua lam sang khdng kem gi phiu thuat[5]. Nhiing nghien cim vl sau cho nhOng tdn thuang mach mau nhilu ting diu cho thiy viec phdi hpp giiia phiu thuat va can thiep mang lai Ipi ich to ldn vl hau phiu cho benh nhan so vdi phiu thuat ddn thuin[l][2]. Nam 1977 Andreas Gruntzig da sang chi dug thdng cd hdng du chic de lan diu tien tren thi gidi thuc hien nong mach vanh. \ a 7 nam sau gia do Idng mach (stent) cho mach vanh ra ddi. Carlos
Parodi (Buenos Aues) nam 1990 lin diu tia dat mach nhan tao DMC bimg thanh cdng (a Tit dd din nay can thiep ndi mach mau ciiM nhu phdi hpp phau thuat va can thiep mach £ phat triln hit sue manh me trong ca linh vyt mach mau ngoai vi, mach mau ldn, mach ijng va tim (mach vanh). Tuy nhien de co thi tri&i khai dupc ky thuat nay ddi hdi nhilu ylu to;
trang thilt bi (may chup mach du tot), vat It tieu hao (day din, bdng npng, stent, thudc can quang...), phdng md hay phdng chup madidi ldn, va dac biet la phai cd bac sT dupc dao tao bai ban. Nhung ngudi cd thi thuc hien can thiep ndi mach la phau thuat vien mach mau.
bac sT ndi tim mach can thiep va bac sT di?D quang. Tuy nhien thep xu hudng chung tren the gidi, vdi cac thucmg tdn khd doi hoi can thiep phiic tap, phdi hpp phau thuat v^ can thiep thi ty le phau thuat vien mach mau tham gia can thiep cang ngay cang chilm vai tro chudao[l][3].
Tai Viet Nam, Benh vien Viet Diic tir nhiing nam 1980 cung da bit diu ap d\mg ky thuat chup mach va thuc hien mdt si can thiep mach thd so, nhd Ie, khdng he thdng (nul mach phi quan, thu thuat Brook dilu tri thoij DM-TM canh xoang hang). Mai tdi nSn^O!, benh vien mdi trang hi dupc may chup i n ^ tai khoa dien quang, va nam 2009 may C-aB tai phong md (khdng danh cho mach mau).
Tdi nam 2011, vdi su ho tra vl kinh nghiem Cling nhu trang thilt bi cda chuyen gia Phap (AIPCV-ADVASE), chiing tdi da thuc l l nhieu can thiep ndi mach cho benh ly m?th mau. Dac biet tir cudi nam 2012, vdi viSc di|
vao su dung don vi can thiep - phau tim mach, chung tdi da cd thi tiln hanh"
trudng hpp hybrid phiu thuSt - can thiep[
nhilu vi tri, cho cac thucmg tdn phiic tap hon.
Theo Nguyin Duy Thing[9], viec ap dull hybrid ban diu tren benh nhan tai dSy cd kit qua tdt, khdng cd tu vong va cac biin chiing cd the kiem soat dudc.
I
TAP CHI TIM MACH HOC Vl£T NAM - S 6 65.2014 iS
Ei^ \ . U U LAM 5ANG
{)ac diem benh nhan va chi d|nh can thiep hybrid
Benh nhan 6hu la nam gioi, 75% benh nhan CO tien sii htit thu6c la, thu6c lao.
Ro rang hiit thuoc la mpt ylu td nguy co cao trong benh ly mach mau noi chung va gSn lien vai giai nam. Tu6i trung binh ctia benh nhan la 70,6 tirang ung voi tu6i mic benh mach mau tai chau Au (62-73 tu6i) [3]. Tu6i trung binh trong nghien ciiu ctia chung toi cao hon trong nghien ctiu v^ benh mach chi du-ai cua Doan Qu6c Htmg nam 2006[7] co le do chat lugng cuoc s6ng, tuoi thg trung binh cua benh nhan tai Vi|t Nam dugc cai thien va benh nhan co dieu kien han de ti^n hanh phlu thu^t-can thiep so voi giai doan truac day.
Chi dinh hybrid cho cac benh nhan diu la cac ton thuang nang va phiic tap, kho hoac kh6ng the xii ly bang can thiep hoac phau thuat dan thuan. Vai ton thuang cua quai
DMC (bang 1) ro rang phau thuat thay quai DMC don thuan la mgt trong nhiing sang chan het stic nang ne cho benh nhan vcd nguy co tti vong cao. Voi benh nhan ton thuang DM chu - chau dac biet neu benh nhan co tien sti mo cu, viec phau thuat vao bung la mgt sang chan nang va ton kem thoi gian. Voi ton thuang mo cu ctia mach chi duoi, viec phoi hgp phau thuat va can thiep cho phep tien hanh dong thoi ca chan doan thuang ton ciing nhu xti ly thuong ton tren nhieu vi tri ma khong can can thiep nhieu vao cac vi tri m6 cii hoac tren nhieu vi tri.
Co the chi dinh hybrid cho nhieu loai ton thuang mach mau khac nhau, ap dung cho benh nhan co ke hoach hoac cap ciiu. Ton thuang mach co the la thuong ton hep, phong mach, 16c ciing nhu tac mach do huyet khoi.
Vi tri mach bi ton thuang co the ap dung het siic da dang cho DM chii, DM chau, DM chi duai va ca cau noi mach nhan tao (bang 1,2).
B5c cau DM canh-canh P-T (BN 1) va dat stentgraft quai DMC
Loc tach type B vo vao khoang miing phoi T
Anh. Hvbrid tren quai DMC vd Ion thucmg nhieu tdng cua mach mdu
38 I TAP CHl TLM MACH HQC V I £ T NAM - SO 65.2014
NGHIEN CtfU LAM SANq^
Anh B.\5v&i tdc DM chau P. hep DM chau T
Cac tham do can Iam sang dugc ap dung irong nghien ciiu chiing loi ta sieu am doppler.
chup mach \ a MSCT (tham do it xam lan. rat tot voi cac mach kich thuac Ion \-a vira). Phoi hgp vai cac tham khdm !am sang kT lucmg \ a toan dien se cho phep chiing ta chan doan \ a xu tri kip thai cac bien chiing.
I'u diem \a nhuoc diem ciia hybrid phau thuat va can thiep
H>brid CO the ap dung dugc cho nhieu vi tri ton thucmg mot luc. trong nghien ctiu cua chiing toi benh nhan bi ton thuong tir mach lorn (quai DMC) cho tai cac mach mau ngoai vi (DM cha\ truac. cha\ sau) vai nhieu tang ton thuang tren cimg mgt benh nhan. Co nhCmg ton thucmg khong the phau thuat nhu ton thuong 16c tach da \ o cua DMC. Can thiep h}'brid cho phep chung toi x.u ly cac thucmg ton mgt each uiel de trong mgt thi. Cac nghien cim tren the giai cOng chimg minh vai tro va im diem ru\et doi ciia hybrid so sanh vai phau thuat hoac can thiep dem thuan \ai cac ton thirmis nJiieu ulng[]].[:].16].
H\brid phoi hop dugc uu diem cua phau ihuai \ a can thiep noi mach. Phau thuat cho phep chung toi bg 16 ro thuang ton. tilp can \ a xu ui nhung mach mau ma can thiep rat kho khan (nhu DM diii chung bj tdc hoan toan.
hmet khoi gay tac trong long mach...). Be:
canh do. \iec can thiep ngi mach cho phe:
chung toi xir ly nhung thuong ton cua mac:
mau loTi (quai DMC) \-a cac vi tri kho. xa(DM chay uuac. chay sau. mieng noi raach ma.
cu) voi nhimg kv thuat tien tien (nong mac'- bang bong, dat stentgraft) mgt each nhait ehong. hieu qua va an toan. Mec phoi hop ca;
uu diem tren da cho phep ehiing toi xir ly duoc edc thucmg ton kho. phiic tap doi khi khon:
the thuc hien duge neu phau thuat hoac cr.
thiep dem thuan. Nhieu nghien ciiu da chimg minli hieu qua phuc hoi luu thong mach mau eua h\'brid khong khdc gi phau thuat nhung cc t\ le bien chiing thap hon. giam thoi gian sue va nam vien eho benh nhan [2]. [3]. Mec tranh dugc cac bien chung do mo ngirc. w xucmg lie. ga\ me. chay md%' tim phoi !a ir.;
the Ion ciia can thiep.
Ben canh nhirng lgi ich eua no. viec ap dung H>brid phau thuat-can thiep cung cc nhiing nhuge diem. Co hai benh nhan cuj ehiing toi gap bien ehiing. mgt benh nhanlL'
\ ong. Nhu va\' \'6i \"iec ap dung H> brid beri nhan co the gap da> dii cac bien ehiing cu3 qua trinh ean thiep ngi mach hoac phau thii' ga\- ra.
Mec benh nhan va nhan vien y te ciing lif?
xiie \ ai phong xa tia X eo ngu}' ca mac ca^
T.^P CHl TLM .MACH HOC MET NAM - SO 65.2014 •"
- r^^nifcHi t;mi m m S A N G
b^nh ly da do phong xa, due thiiy tinh the cao hon nhieu lan da dugc chiing minh vai nhieu baiig chiing khoa hgc[l]. Ben canh do voi chi phi cao ctia can thiep mach mau, viec bao hiem y te chua chi tra cho toan bg qua trinh dieu tri, viec ap dung Hybrid ro rang la mgt ganh nang kinh te cho benh nhan va gia dinh benh nhan.
Mgt han che khong nho cua viec ap dung Hybrid tai Benh vien Hiiu nghi Viet Diic la trang thiet bi, vat tu cho can thiep-phau thuat con chua day dii, nhan lyc cua chiing toi chua co nhieu kinh nghiem trong viec ap dung cac ky thuat moi, tien tiln ciia can thiep ngi mach cho benh nhan. "Viec bo sung vat tu thilt bi ciing nhu khong ngung trau d6i chuyen mon, hgc tap ky thuat moi va mo rgng hgp tac se giiip chiing t6i co nhieu dilu kien, kinh nghiem hon trong dieu tri cho benh nhan.
KET LUAN
Tuy moi bat dau dugc triln khai nhung voi nhung uu dilm nii trgi va kit qua som r4t tit, phoi hgp phlu thuat va can thiep ngi mach (hybrid) la mgt huang di dung dSn c4n dugc nghien Cliu mor rong cho cac benh ly mach mau phitc tap. Tuy con nhilu kh6 khan nhu trang thilt hi con thieu, chi phi y tl con cao va nang luc con nguoi con han chi. Viec lira chgn benh nhan phii hgp, dao tao nhan luc chuyen sau, thuc hanh thuang xuyen, trang bi d4y dii, cai thien chi do bao hiem xa hgi se giiip phuang phap dilu tri nay cho kit qua ngay mgt tit hon tai Viet Nam.
SUMMARY
Treatment of complicated vascular diseases with combined open surgery and endovascular interventions (hybrid).
Doan Quoc Himg*, Nguyen Duy Thang*
Nguyin HQu Uac*, Phgm Qu6c Dat*
Le Thanh Dung*, Nguyin Lan Hieu**
* Viet Due university hospital ** Hanoi medical university hospital
Complicatedvascular disease includes lessions of important positions of the vascular system (aortic arch anddescending aof la) or multi-level lessions in PAD. Application of Hybrid procedia-es: open surgery and endovascular intei-ventions in now becomes Ihe common trend in treatment of complicated vascular diseases worldwide due lo its advantages results of treatment and economic burdens. We apply Hybrid procedures in 11 patients at I iet Due University Hospital during 2011- 2013. in -which 8 cases are peripheral arteriopathy (PAD) and 3 cases are aortic arch disease The early results is good Technique is feasible; low morbidity, patients get rid of symptoms and The medical fee is acceptable for the patients familv However the application of these procedures remains difficulty for most of our patients due to lack of man power; medical equipments and the insurance issue We needfitrther research for this kind of treatment
Kej'words: Hybrid, vascular intervention, combined surgery and intervention
40 I TAP CHl TIM MACH HOC VI$T NAM - S6 65.2014
NGHIEN CtfULAlW Si
TAI Ulu THAM KHAO
1. Alan T. Hirsch et al. (2006) ACC AHA 2005 Practice Guidelines for the Management of Patients With Penphtn Arterial Disease (L<mer Extremity. Renal Mesenteric, and Abdominal Aortic) 'A Collaborative Report from the.imai^
.issocialionfor Vascular Surgery'Societyfor Vascular Surgery.* Society for Cardiovascular Angioff-aphy and Imervemioi Society for Vascular Medicine and Biology. Society of Interventional Radiology, and the ACC/AHA Task Force on Praoxf Guidelines (Writing Committee to Develop Guidelines for the .Management of Patients With Peripheral Arterial Diseati Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation: SaJional Heart. Lung, ^y Blood Institute. Society for Vascular Nursing: TransAllanlic Inter-Society Consensus: and Vascular Disease Foundoui Circulation.ll3:e463-e654
2.Antoniou GA, Sfyroeras GS, CKarathanos. (2009) Hybrid endovascular and open treatment of severe multilet^
lower extremity arterial disease Eur J Vase Endovase Surg 38:616-622.
3,Goodney P.Philip, Robert M Zwolak. (2009) National trends in lower extremity bypass surgery, endovasoAr inlervenlion, and major amputations. J Vase Surg 50: 54-60.
4. Misty M. Payne. (2001) Charles Theodore Dotler The Father of Intervention Tex Heart Inst J. 28(1): 28-38.
5 Porter JM,EidemiiierLR, DotterCr.Rosch J,VettoRM: (1973) Co/nA/MetyarteWa/t^//oto/io«anrf^morq/em^
bypass for limb salvage. Surg Gynecol Obstet 137:409-412
6. P.-S. Abo, M. Venemio. (2012) Hybrid procedures as a navel technique In the treatment of critical limb ischem Scandinavian Joumal of Surgery 101: 107-113.
7.Do4n Quoc Himg, Ding Hanh DS. (2006) Mot sd dgc diim ldm sang, cdn ldm sang vd diiu tri phdu thuat ihiiuiia chi du&i mgn tinh do viraxadong mach Tap cbi y hgc Viel Nam 324,7:21-30.
8. Do^n Quoc Htmg. (2011) Can thi^pngi mgch va phdi hap phdu thudt mo m&- Can ihifp noi mach. xu hu&ngm trong dieu trj bfnh mach mdu. Tap chi nghien ciru y hoc: 80;354:64-60.
9. Nguyen Duy Thing, Doan Quoc Hirng, Nguyen Hihi t o e , Pham Qu5c D a t (2013)-A:eV qua phdi h(?p phdu ^ va can thiep ndi mach mdt thi (hybrid) Irong diSu tri benh ly mach mdu tai benh ^ien him nghi Uet Due". Tap chiyta thirc hanh 7(876)- 44-47.
T6m tat: Ciing v&i suphdt then cua xa hdi. cac benh ly mgch mdu xudt hi?n ngdy cdng nhiSu v&i tdn thuong phuc U/f, nhieu tdng. o cdc vi hi ngin' hiem tren cdc benh nhdn nhiSu tudi. cd nhiiu benh phdi hap. Phdi hap phdu thugt va can ihOf ndi mgch (hybrid) trong diiu tri benh ly mach mdu khd hien dang Id xu huong phdt triin chung tren thi gi&i do nhiing^
diem vu(rt trdi cua no so vdi can thiep hoac phdu thudt don thudn Chung tot dp dung hybrid cho 11 benh nhdn lai Bfii ''•^"f1^"ShimtDuctundm20Udin2013t,-ongdd8trudnghopdpdungchobenhmgchmdungoaibienva3lr^
hop dp dung cho benh quai DMC va DM chO xufing Kit qua ban ddu khd quan: Thdnh cong vi ky thudt cao. khongcoti vong lien quan den hybrid bien chung co the kiem sodt duac. trieu chimg ldm sang duac cai thien ro ret vd chiphiphk '^'^'-^-"''^^^P^'^^cdd gia dinh cd the chi trd Tu,'nhien viec dp dung ky thugt ndy cdn gdp nhiiu kho ^^^
''^•''•^"S'hietbicuachungtdicdnchuadA-du.gidthdnhcdncaosovdisdddngbenhnhdnvdbdohiemytichuaM toan Day Id mdt huang di mai hieu qua cdn nghien cuu vd dp dung idng rdi trong ldm sdng
TCr kh6a: Hybrid, can thiep noi mach; can thiep noi mach ph6i hop phSu thuat.
TAP CHI TIM MACH HOC VI$T NAM - S 6 65.2014
