TAP CHl Y HOC VlfeT NAM TAP 465 - THANG 4 - SO 2 - 2018 TAI UEU T H A M KHAO
1. Yu SW et al (1988) Tears of the annulus fibrosus:
correlation between MR and pathologic findings in cadavers. AJNR Am J Neumradioi 9:367-370.
2. Osti OL, Fraser RD (1992) MRI and discography of annular tears and intervertebral disc degeneration. A prospective dinieal comparison.
Bone Joint J 74:431-435.
3. Cloward RB (1952), anterior herniation of a ruptured lumbar intervertebral disk. Arch surg; 64: 457-63
4. Yu SW, Sether LA, Ho PS, Wagner M,
Haughton VM. (1988). Tears of theannulus fibrosus : correlation between MR and pathologic findingsin cadavers. AJN1988; 9:367-70.
J . Yu SW et al. 1998. Annulus fibrosus in bulging intervertebral disks. Radiology 169; 761-3.
6. Michael N. Brown. Annular tear or fissure "the Great masquerader". Available from: URL:
https://vvwvK.michaelnbrownmd.com/michaelnbrow nmd/files/TheAnnularTearNewEdit.dQe.pdf.
7. Sharma et at.20O9. Association between Annular Tears and Disk Degeneration: A Longitudinal Study. Am J Neuroradlol 30:500-06.
K H A O S A T H I N H T H A I DONG MACH CHO NGITC VA CAC BIEN THE GlAl P H A U VCJNG CUNG DONG MACH CHfi
Nong H&u Thg*, Vo Nguyin Thanh Nhan**, Pham Tho Tudn Anh*
T O M TAT
Muc tieu: Do dae cae kfch thu'dc ciia DMC ngi/c, khao sat cac dang hmh thai va t / le cac bien the giai phau viing cung DMC. DSi lu'dnc) va phuVng phap nghien cu'u: Md ta hdi ciiu, hang loat cac tru'dng hdp.Tat ca eac benh nhan du'dc chup cat idp vi ttnh viing ngi/c cd can quang, bSng may eSt Idp vi tfnh MDCr320 (Aquiiion one) tai khoa C[, Trung tam y khoa Medic Hda Hao tir 1/2016 den 12/2017.-Ket qua: Khao sat 450 cae tru'dng hdp (232 nam/218 nd), dp tudi trung binh 46.3±21. Ghi nhan du'dc cac kfcli thudc cda DMC ngUc theo cac phan doan: ST junction: 25.59±3.2; Doan len: 28.81±2.9mm'; Doan cung: 25.89±2.5mm; Doan xuong: 23.85±3.3mm.
Hinh thai DMC ngi/c: Hinh thai kinh diln: Cunp DMC nam ben trai va 3 nhanh ben xuat phat dieo thU tu' tir phai sang trai la: TliSn DMCTD - DMCCT -^DMDDT chiem cao nhat 96,6%. Hinh thai bien the Bovine arch; mau hinh nay cung OMC chi ed 2 nhanh ben, con DM canh chung trai thi iai nhap vao than DM CTD:
2.4%. Hinh thai OM dot sSfig trai xuat phat tir eung OMC: 1.1%. Chua ghi nhan tru'dng hdp OM du'di don phai lac cho. Ket luan: Khao sat kich ttiUdc, hinh thai cung nhu nhiTng bieh the giai phau eiia eung DMC ed
^ nghTa quan trpng. Chup CLVT la mdt phUdng tien khao sat de thi/c hien, cho hinh anh ro rang, day dii ve dSc diem hinh tJiai DMC ngi/e cung nhu' cac bien the xuat phat tir viing cung.
Td khda: Q^c diem hinh thai ddng mach^ehu ngUc, eung dpng mach chii ngu'c, bien the giai phau.
SUMMARY
ASSESSMENT OF THE THORACIC AORTA MORPHOLOGICAL CHARACTERISTICS AND
*Benh vien 175,
**Trung tim y khoa Medic
***Tnj&ng Dal hgc Y Dddc TPHCM Chiu trach nhiem chfnh: Ndng Hihi Thp Eniail: [email protected] Ngay nh|n bai: HZIIQI^
Ngay phan bien khoa hoc: 5/4/2018 Ngay duylt bai: 16/4/3028
ANATOMICAL VARIANT OF THE AORTIC ARCH Objecdves:The aim of this study was to investigate the frequency and gender distribution of variations in the aortic arch branching pattern using Aquiiion One 640-Slice computed tomograhic angiography. Materials and mediods: A descriptive study was conducted in a series of 450 patients, induding 232 males, 218 females, in Medic Center from 1/2016 to 12/2017. A total of patients who underwent computed tomographic angiography for various reasons were analysed retrospectively for the frequency of variation of aortic arch branching and were measured the diameters of the thoracic aorta segments. Result: There are 450 patients with a mean age of 45.3±21, 232 mates (51.55%) and 218 females (44.44%). The morphological characteristics:
type 1 - the common morphology: 96.6%; the frequency of type 2 variation (Bovine Arch) - brachiocephalic and left common carotid arteries arising from the aortic arch in a common trunk - was 2.4%, that of type 3 - left vertebral artery originating fnam the aortic arch - was 1.1%, that of type 4 - aberrant right subclavian artery - was not regconized.
The values for thoracic aortic diameter (AD) were recorded at many segments: the sinotubular junction:
25.59±3.2mm, mid-ascending: 28.81±2.9mm, transverse arch: 25.89 ± 2.5mm, mid-descending:
23.85±3.3mm. Conclusion: Recognition of variations of aortic arch and assessment of the thoracic aorta morphological charactenstics are very imporiant.
Because thank fbr all invesdagtions, the surgeons and intervetion'ists have the feasit^ strateg/s treabiient fbr AA5.
Key words: Thoracic aorta morphological characteristics, aortic arch, anatomical vanant.
I.
OAT VAN DEHot chuTig ddng mach chu cap tinh (HC DMC) la mpt khai niem du'dc dda ra gan day nham chi nhieu benh canh cap ciTu, lien quan vdi nhau, giong nhau ve dac diem lam sang va dien tien.
Oay la mpt trong nhdm benh canh cap cdu nang ciia HS-PT tim, bdi d i l n tten nhanh va ty le tir
VIETNAM MEDICAL JOURNAL H*^ • APRIL - 2018 vong kha cao neu khdng du'dc xur tri kjp thdi.
Neu khdng dieu t n , ty le ti^ vong la 50% trong 48 gid dau, 80% trong 2 tuan dau va 92% trong_
1 nam. Cd nhieu phu'dng tien du'dc dimg de chan doan HC BMC cap, nhd dien tam do, sieu am, chup cdng hu'dng tir, ehup mach can quang qua da... nhutig trong dd vai trd ciia chup cat Idp vi tinh (CLVT) de md ta hinh thai l»n thu'dng DMC da du'dc nhan manh trong khuyen cao ciia Hdi Tim Mach Hoa Ky nam 2010 va Hot Tim Mach chau Au (ESC) 2014.
Ngay nay, chup X quang cat Idp vt tfnh cd can quang la ky thuat ft xam lan, thdi gian ngan, chi phf thap; cho ehat lu'dng hinh anh tdt va nhat la vdi ky thuat diTng hinh da ehieu bang phan mem cho phep khio sat dddc toin bg hinh thii dgng mach chu ngdc vi esc bien the giii phau.
Viee khao sat hinh that ddng maeh chii ngiTc va cac bien the giat phau vimg cung o5 y nghTa quan trpng trong thiTc hanh lam sang, lam cd sd trong viec danh gta, tien lu'dng, de xuat hu'dng xir trf OMC: p h l u thuat hay can thiep mdt each hdp ly. 6 Viet Nam cac BS chan doan hinh anh, can thiep mach va cac bs phau thuat tim eung ehuei ed nhieu de tai ve khao sat hinh thai OMC va cac bien the giai phau vimg cung de gdp phan cho cdng tac ^ u trj HC DMC cap. Do vay, ehiing tdi tien hanh nghien cdu de tai nay nham khio sat die diem hinh thai ddng mach chu ngut ra mdt sd bien the giii phau vung cung DMC du^ tren chup CL VT.
II. o d l TUQIMG VA PHU'OIMG PHAP NGHIEN COXJ 2 . 1 . Ool tu'dng n g h i e n cii'u: Tat ca cae benh nhan du'dc chup cat Idp vi tinh vting ngdc ed can quang, vdi may MDCT320 (Aquiiion one) tai khoa CV, Trung tam y khoa Medic Hda Hao tir 1/2016 den 12/2017.
Tieu chuan loai tru"
- Ddi tu'dng da du'dc md/can thiep; OM vanh, DMC ngu'c, van tim.
- Cd chong chi djnh tiem thudc can quang:
Suy than (eGFR <30ml/phut), cu'dng giap.
-Ten sij'di uhg vS thuoc can quang, |^y niJcd that.
2.2. Phu'dng phap n g h i e n cii'u: Nghien ciru md ta hdt cihi, hang loat ca.
Xd ly so HSu: So lieu du'dc nhap bang phan mem Mtcrosolf Office Excel va xii" ly thdng ke bSng. SPSS. Xac djnh sd ca, ty le phan tram, trung binh eac bien so ghi nhan dirde diia tren cac tteu chi da du'a ra.
III. KET QUA NGHIEN CO'U 3 . 1 . Oac d i ^ m c h u n g v e b | n h n h a n
Bang 1. Phan bo benh nhan theo gidi Gidi
Nam Tong cdng
m
So b e n h n h a n 232 218 4 5 0
Ty le % 51.55 48.44 100 Nhan xet: Sd lu'dng nam va nii' du'dc chon tu'dng du'dng nhau, t?/ le benh nhan nam va nif g a / i g Z Tuoi trung binh cua mau nghien eihi
So
lu'dngT u o i n h o n h a t
T u o i Idn n h a t
T u o i t r u n g b i n h
Dpledi chuan Nhan xet: Tuot BN nhd nhat: 18 t u d i ; tti?
BN Idn'nhat: 78 t u d i ; trung binh : 46.3 ± 21.6 ' Bang 3. Phan bd benh nhan theo tudi
Tuoi
1 8 - 3 0 3 1 - 4 0 4 1 - 5 0 5 1 - 6 0 6 1 - 7 0
> 70
Tong congN 35 86 186 79 53 11
450Ty le (%) 7.7 19.1 41.3 17.6 11.8 2.4
100 Nhan xet:- Nhdm benh nhan 41-50 tudi gap nhieu nhat chiem ty le: 41.3%,
- Nhdm benh nhan <70 tuoi chi ehlem 2.4%
- Benh nhan cao tuot nhat: 81tuoi - Benh nhan thap tuoi nhat: 18 tudi - Do tudi trung ijinh ciia nam la: 48,4; dd lecti chuan: 22,7
- Dp tudi trung binh ciia nO' la: 44.3; dp lech chuan: 20.1
3.2. Kich thu'dc n g a n g cua ddng mach c h u ngu'c
Bang 4: Kfch thu'dc ddng maeh ehii theo phan doan
Kich t h i r d c BMC ST junction
Ooan len Cung Ooan xuonq
N a m 26.01±3.5 29.14±2.8 26.16±1.9 24.08±3.1
Nir 25.23±2.9 28.54±3.2 25.73±2.7 23.79±3.6
Chung 25.59±3.:
28.81±2.!
25.89±2.!
23.85±3.3 Nhan xet: Du'dng kfnh ngang ciia OMC ngi/c Idn nhat d doan len gan cung sau do giam dan den doan xuong.
3.3. Cac m a u h i n h t h a i v u n g cung DMC Bang 5: Cac mau hinh that cung DMC trong nghien eiTu
M a u h i n h Hinh thai !<inh dien Hinh thai Bovine arch Hinh thai OIvjOS trai xuat
So lu'dng (nj 435 11 5
Tyle 96.6
»/»
2.4 1.1
TAP CHi Y HOC VIET NAM TAP 465 - THANG 4 - S6' 2 - 2018 phat tir cunq DMC
Hinh thai DtA\X) phai lac chd 0 0 Nhan xet:
- Hinh thai kinh dien: Cung OMC nam ben trai va 3 nhanh ben xuat phat theo thu' tu* tir phai sang trai la: Than OMCTD - DI^ICCT - OMDOT chiem cao nhat 96,6%.
- Hinh thai bien the Bovine arch: Mau hinh nay cung OMC chf cd 2 nhanh ben, cdn OM canh ehung trai thi iai nhap vao than DM crO:2.4%
- Hinh thai OM ddt song trai xuat phat tir cung OMC: 1.1%
- Chu'a ghi nhan tru'dng hdp OM du'di ddn phai lac cho.
Bang 6: Hinh dang dpng mach canh ehung DMCC phai va trai
Thanq Gap l<h(jc va uon conq
So iUtfng ( n ) 407 43
T y l e 90.44%
9.56%
IV. BAN LUAN
Nghien eiru ciia chimg tdi du'dc thiet ke theo phu'dng phap mo ta hoi ciTu hang loat cae tru'dng hdp. Thiet ke nay phii hdp vdi mue tieu de ra ban dau la md ta cac kfch thu'dc, hinh that bien the giai phau ciia OMC ngu'c va eung OMC di/a tren hinh anh MDCT (cat Idp vi tfnh da lat cat) va xac dmh ty le, gta trj trung binh ciia timg Ioai bien the, kfch thu'dc timg phan doan eiia DMC ngi/c.
Diem qua mdt SO nghien ciiu khac tren the gidi cd lien quan den de tai nhu" nghien cdu ciia Berko do tren 1000 benh nhan d Bronx, NY, USA (Hoa Ky) nam 2009; Jakanani phan tfeh hinh thai cua 861 benh nhan d Leicester, UK (Vu'dng qudc Anh) nam 2010; Natsis bao eao 633 benh nhan dThessaloniki, Greece (Hy l^p) nam 2009... Tac gia Le van Cu'dng ciia Viet Nam khi nghien eiTu ve cac nhanh ben cua cung DMC cung khdng tfnh den ty le xuat hien cua cac bien the ciia rieng tirng gidl nam, nii' ma cung chi md ta hang loat tru'dng hdp vc^ c3 mau v u ^ dii.
Ve ich thu'dc DMC ngu'c it cac doan: Cac tae gta trong nu'dc va ngoai nu'dc ghi nhan ket qua nhu' sau. Tac gta Le Van Cu'dng (1991) do OMC tren xac u'dp ghi nhan: DMC doan ten : 21.73mm; doan cung: 19.i0mm; doan xuong:
15.76mm. Tac gia Nguyen Tuan Vu khao sat bang CLVT tren 131 ngu'di ghi n h i n : OMC doan ten: 32 mm; doan quat: 25mm; doan xuong: 24 mm. Tac gia Torsten B, Moeller va Emit Reif cung khao sat bang CLVT va MRI: bao cao: DMC doan ten: 32±5mm; doan quat: 25mm; doan xudng:
25±4mm. Tae gia Aronberg D.J cimg cdng siT, do tren CLVT: DMC doan len: 35mm; doan xuong : 24-26mm.Tac gia Raudault R. Do tren sieu am qua thanh ngi/c: DMC doan ten: 25- 38mm; doan eung: 24-32mm.
Trong nghien ciTu eua chiing toi, khao sat bang CLVT da dau dd vdi dd mau 450 ngu'di:
nhan thay kfch thu'dc OMC doan len: 28.81±
2.9mm; doan cung: 25.89 ± 2.5; doan xuong:
23.85± 3.3mm. Tuy nhien, trong nghien ciru nay, chOng tdi cd do dae them kfch thu'dc eiia khdp noi xoang dng ST-junetion: 25.59 ± 3.2mm. Cae nghien cii'u da phen deu nhan thay, DMC doan len dat kfch thu'dc Idn nhat, sau dd giam dan khi ra xa xudi ddng. Tuy nhien cd sir khac biet vdi cac tac gta khac, ed the dophan bd dp tudi giii^ cac nhdm chu'a dong deu; can nang va chieu cao ngu'di Viet Nam cd the khac biet vdi ngu'di Au-My.
Ve ty \% cac bien the giai phau: Theo y van the gidi, eae tac gia khi nghien eiTu ve cac bien the giai phau eac OM Idn xuat phat tir eung OMC deu lay mau hinh thai kinh dien lam chuan.
Theo mau hinh kinh dien thi 3 OM idn xuat phat tir eung DMC bao gom: (1) than DM eanh tay dau, (2) OM canh ehung trai va (3) DM du'di ddn trai, theo thd tiT tir phai sang trai. Bat cir siT bat thu'dng nao so vdi mau hinh kinh dien tren deu du'dc gpi la cae bien the giai phau. Ty le nay cd sd khac biet giii^ cac tae gta nghien eiili.
Nghien ciru ciia Natsis tren 633 BN d Hy Lap thi ed 8 mau hinh bien the vdi ty le la 16,59%.
Tae gia Berko khao sat tren 1.000 BN d New York, Hoa ky thi cd 7 mau hinh bien the vdi ty le la 32,4%. Theo Muller do tren 2.033 BN d Ulm', Du'c thi ed 6 mau hinh bien the vdi ty le la 13,3%. Theo nghien ciru ciia tac gia Le van Cu'dng vdi ed mau la 62 da phat hien du'dc 3 mau hinh bien the, ty le la 6,5%. Nghien cu'u ciia chung tdi, ghi nhan tdng so bien the giai phau la 3.5% (16/450) (gom ca nhdm Bovine arch va nhdm DM ddt sdng xuat phat tir quai OMC).
Hinh thai Bovine arch dddc djnh nghTa, la,
"sy" nhap ciia DM canh chung trai vao than DM canh tay dau" hoac DM canh chung trai xuat phat trirc tiep tir than DM canh tay dau chii*
khdng nhap chung vao than DM canh tay d3u.
Khoang each tir ndi xuat phat den cung OMC dao ddng tir 1cm den 2,5cm.
Theo y vSn the gidi thi day la bien the hay gap nhat, vdi ty le lu'u hanh khoang 10% tdi 20%. Khi dd cung DMC cd 2 nhanh ben la: Than Chung OM canh tay dau - OM canh chung trai va
VIETNAM MEDICAL JOURNAL H°2 - APRIL - 201B OM du'di ddn trat. Tac gia Celikyay eung canh
bao d hinh thai "bovine arch" cd 2 cho hep gay khd khan cho viee dat stent la cho hep giu'a eung
DMC- than DM canh tay dau va cho hep giu^
than canh tay dau-DM canh chung trai.
H/nh 1: Mau hinh Bovine arch dngUdi
H/nh thai ddng mach ddt sdng irai xuat DMDS trai cd the nam ben phat hoac trai cua phai id cung ddng mach chu. Trong bien the
nay, DMDS trai khdng xuat phat tir DMDD trai ma xuat phat tru'e tiep tir eung OMC .Ve vj trf.
DMDO trat. Trong nghien cu'u nay, chiing tdt eo 5 tru'dng hdp DMDS trai xuat phat tru'e tiep tii"
cung OMC, chiem ty le 1,1%.
Hinh 2: DMDS t/ai xuat phai trdc tiep tu'cung DMC Hinh C: DMDS trai xuat phit trut tiep tdcung DMC vi nam ben phil DMDD trii
Hinh D: DMDS tiii xuat phat trdc tiep tii" cung DMC, nam ben phil DMDD trai vi ket hep vdi bovine art.
Hinh E: DMDS tiii xuat phat dut tiep tdcung DMC, nam ben tiii DMDD tiii vi ket hdp vdi bovine art Hinh F: DMDS tral xuat phit trdc tiep td cung DMC va nam ben tral DMDD tral.
Mpt so nghien cuTu tren the gidi ghi nhan kieu hinh tiiai bien the : DMOS trai xuat phat trdc tiep tir cung DMC nhieu hang thu' 2 sau mail hinh Bovin arch, ty le dao ddng tir 3% den 8,3%.
Theo nghien cu'u ciia Cavdar va Arisan (1989): ty
^e nay la 8.3%. Theo Vorster (1988) khao sat t^
j f ,£ll^,dot sdng trat xuat phat tir cung dmc la 5^.T^ le n^y tu'dng du'dng vdi nghien ciTu ciia Panicljervya cdng sir (2002).
ly/KlfLiJAN
• 'khao sat kich thu'dc hinh that cung nhu' nhiilig bien the giai phau ciia quat DMC cd y nghia quan trpng. Chup XQCLVT la mpt phu'dng tten khao sat de thyc hien, cho hinh anh ro rang, day dii ve dae diem hinh that DMC ngt/c cung nhu' cac bien the xuat phat tir viing quai. Tren cd sd dd, cac phau thuat vien tim mach ciing nhu' cae bac si can thiep cd the liTa clipn du'dc phu'dng phap tiep can, chien thuat xd tri cac tSn
thu'dng DMC mdt each phii hdp nhat, de tang ty le thanh cdng cung nhu" giam thieu tdi da cae bien ehirng cd the xay ra.
TAI UEU T H A M KHAO
1. Le Van Cu'dng (1991). Cac dang va di dang dia dong mach d ngu'di Viet Nani, Oat hoc V DuBc thanh pho Ho Chi Minh.
z. Pham Ngoc Hoa, Le Van Phu'dc (2008), a ngirc, Nha xuat ban Y hoc, TPHCM.
3. Acar M, Ulusoy M, Zararsiz Z, Efe D (2013),
"Anatomical variations in the branching of human aorte ardi". Biomedical Research 2013; 24(4), w- 531-535.
4. Vitacosta I , San Roman JA (2001), "Acute aortic syndrome". Heart (85), pp. 365-368.
3. Viscomi S.G. (2008), "Chapter 5: Omputed tomography",in: J.S. Conselli, S.A. Lemaire, Aortic, Arch Surgery, Blackwell, West Sussex-UK, pp. 39-57., 6. Celikyay, Koner, Celikyay, et at. (2013).^
"Frequency and imaging findings of variations ih, human aortic arch anatomy based on multidetectof computed tomography data". Clin Imaging, 37(6),>
pp. 1011-9.
