TAP CHlY DUOC LAM SANG 108 T^p 12 - So 4/2017
iTng dung can thiep mach trong dilu tri hoi chung sung huygt tieu khung: Nhan 4 truong hop duffc dilu t n thanh cong tai Benh vien Bach Mai tir 5/2016 din 11/2016
Application of vascular interventions in the treatment of pelvic congestion syndrome: 4 cases in Bach Mai Hospital from May 2016 to November 2016
Nguyen Xu3n Hien, hi Van Khanh Benh vien Bgch Mai
Tom tat
Muc tiiu: Can thiep ndi mach gian tTnh mach budng trUng trai gan day dupc sCf dung trong dieu tn hdi chUng sung huyet tieu khung. Budc dau danh gia hieu q u i l l m sang va tinh an toan cua phUdng phap gian tTnh mach budng trUng trong dieu tri hdi chUng sung huyet tieu khung. Ddi tugng vd phuang phdp: Md t l can thiep va theo ddi dpc theo thdi gian tU thang 5/2016 den 11/2016,4 benh nhan (tudi trung blnh 33,5 + 10,5, tU 30 - 53 tudi), ed trieu ehUng dau bung tieu khung man linh, dupc chup cpng hudng tU hoac eat Idp vi tinh cd gian tTnh mach budng trUng trai. Cac b i n h nhan dugc can thiep nut tac tTnh mach budng trUng trai bang coil k i t hpp keo Hystocryl. Tien hanh danh gia trieu chUng dau t r i n lam sang theo thang diem Vas trude va sau nut mach 6 t h i n g , danh g i l cac tieu chf ky thuat can thiep: T^' l i thanh cdng va bien chUng. Ket qud: Ty le thanh cdng eua ky thuat la 100%, khdng co tai bien trong qua trinh can thiep va sau can t h i i p . Trieu chUng dau cli t h i i n 100%, tU 7,7 ± 1,5 trUde nut mach giam xudng 2,6 + 2,5 sau niit mach 6 thang. Kit ludn: Can t h i i p ndi mach gian tTnh mach budng trUng budc dau cho thay la an toan, hieu q u i trong cai thien trieu ehUng lam sang trong dieu trj hdi ehUng sung huyet tieu khung.
Tdkhda: Hdi chUng sung huyet tieu khung, can thiep g i l n tTnh mach budng trUng trai.
Summary
Objective: Ovarian vein embolization has been used recently to treat pelvic congestion syndrome.
The purpose of this study is to evaluate the initial clinical efficacy and safety of ovarian vein embolization in the treatment of pelvic congestion syndrome. Subject and method: Follow-up from May 2016 to November 2016, we performed ovarian vein embolization in 4 patients (mean age, 33.5 years; range, 30 - 53 years) had chronic lower abdominal pain and were found varicose veins ovary by MRI or CT scanner.
Embolization was performed with a mixture of coil and hystocryl in all patients. Evaluating the clinical pain by Vas index before and after 6 months embolization, success and complication rate. Result The initial technical success rate was 100%. There no complications. Clinical symptomatic relief in 100% of cases, from 7.7 + 1.5 index to 2.6 ± 2.5 index after 6 months embolization. Conclusion: Transcatheter embolization ofthe ovarian veins is a safe and effective procedure.
Keywords: Pelvic congestion syndrome, ovarian vein embolization.
^gdynh$n bdi: 16/03/2017. ngdy chdp nhdn ddng: 30/03/2017
Nguaiphdn hoi: Nguyen Xuan Hien, Email, [email protected] -Benh viin Bach Mai
JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY Vol.12-NWJOl?
1 . Dat van de
Hdi ehUng sung huyet tieu khung (PCS - pelvic congestion sydrome) I I tinh trang dau man tfnh vung bung dudi khdng l i i n quan den ehu ky kinh nguyet, keo dai > 6 t h i n g va ed kem tinh trang suy gian cle tTnh mach budng trUng [1], Co che b i n h sinh ciJa PCS do sU suy yeu cua h i thong van tTnh mach lam eho trao ngupc ddng c h l y tU tuan hoan tTnh mach (TM) chu ra TM sinh due, hau qua I I U t r i tuan hoan d ngoai vi, lam eho c l e tTnh mach sinh due gian ngoan ngoeo gay dau bung dudi do sung huyet d tU cung, budng trUng va am dao. Cd k h o i n g 15% phu nU dd tudi 20 - 50 cd suy gian tinh mach trong ti^u khung m l khdng ed trieu ehUng gi (dupc phat h i i n tinh cd). V i chan doan cd the dua vao chan d o l n hinh I n h hole md ndi soi tham dd. Cac phuong t i i n chan d o l n phd bien nhat hien trong xae dinh tinh trang suy g i l n eae tTnh mach budng trUng I I s i i u I m qua d I u dd am dao/trUe trang, chup eat Idp vi tinh (CT scanner), cdng hUdng tU (MRt), tuy n h i i n h i i n nay tieu chuan vang la chup tTnh mach (Venography) [2]. V i phuang phap dieu t n n g o l i dieu trj ndi khoa (diing hormon) cd 2 phuang phap dieu trt bd sung chinh bao gdm phau thuat that tTnh mach budng trUng va can thiep npi mach g l y bit tac d i m rdi tTnh mach budng trUng.
Mdt sd nhupe diem cua phau thuat bao gdm thdi gian nam vien dai, p h l i t r l i qua gay me kem mdt sd tai bien trong phau thuat khac, mdt sd nghien cUu da ehi ra ty l i that bai eua phau thuat la 33%, t;^ l i t l i phat 20% [3]. Can t h i i p nut mach cd t h ^ c l i t h i i n eae nhuoc diem t r i n nen dugc xem I I Uu t i i n khi chpn lUa cho dieu t n hdi chUng nay. T r i n the gidi hien tai da ed mdt sd bao chi ra ty le giam trieu chUng lam sang tU 70 - 100% [4], [5]. CJ Viet Nam h i i n ehua cd bao eao v i can t h i i p nut gian tTnh mach budng trUng do dd nhan 4 trudng hpp d i i u trj thanh cdng tai B i n h vien Bach Mai de trinh bay cleh khai q u i t ve van di tren.
2. Dot tupng va phUOng phap 2.7.Dd7tW0tg
Gdm 4 b i n h nhan (BN) dupc chan d o l n x l e /VMn xet; Tudi trung binh cOa b i n h n h i n la 33,5 tu^i dmh hpi Chung sung huyet tieu khung do gian tTnh trong dd eao nhat la 53 tudi. '
mach budng trUng va d i i u tri bang can thiep mad' tai B i n h v i i n Bach Mai tU 5/2016 den 11/2016.
Tieu chuan lua chgn: BN ed dau bung man tinli vung tieu khung t r i n 6 t h i n g va dieu tri ndi khoa khdng d d , dupe sieu am doppler v l chup cat I6p vi tfnh (CLVT) mach mau chan doan xae djnh co gian tinh mach budng trUng v l tTnh mach vung tilu khung, dUOc tien hanh dieu t n bang phuong phap nijt tTnh mach budng trUng.
T i i u ehuan chan doan x l e djnh gian tTnh mach budng trUng tren CLVT hay chup mach: Budng kinh eua cac tTnh mach (budng trUng, tCf cung, mac treo tU cung - buong trUng) > 10mm. Cd ddng trao ngupc thude can quang sang ben ddi dien.
Tiiu chuan logi trCr: Benh khdng ed trieu ehiing lam sang, benh nhan ed eae chdng ehi dinh vdi chup mach.
2.2. Thietke
Nghien cUu md ta, can thiep va theo doi doc theo thdi gian.
2.3. X&l^ so lieu
SCr dung phuong phap thdng ke y hpc.
Cac bien sd n g h i i n cUu: Tudi, sd lan sinh con, s6 ben can thiep, trieu chUng dau bung tinh theo thang diem Vas trUdc nut mach va sau nut mach 6 t h i n g , dudng kfnh tTnh mach t r i n MRI, CLVT mach mau va t r i n DSA.
Phan mem xU ly: SPSS 16.0.
3. Ket qud
3.1. TudX benh lylcem theo
Bdng 1 . Tudi va so lan sinh con Tudi (n = 4)
Trung binh 33,5 ± 10,5
Min/Max 30/53
Sdiansinhcon(n=4)
Trung binh 3,5
Min/Max 3/5
TAP CHf Y DJOC LAM SANG 108 Tap12-Sd 4/2017
3.2. Mufc do dau theo thang diem Vas va thcfi gian dau trung binh tru&c mit mach
Bang 2. IVIu'c dg dau t h e o t h a n g d i e m Vas va t h d i g i a n d a u t r u n g b i n h trUdrc n u t mach
3.S. Dac diem dau theo thang diem Vas trade va sau ntit mach 6 thang
Bang 6. Gia t r i t r u n g b i n h mUc d o dau t h e o t h a n g dtem Vas t r u d c va sau n u t mach 6 t h a n g
Mure do dau (dietn) (n = 4)
Trung binh 7,7 ± 1,5
Tli the aCMg 7,9 ± 2,1
Tuthe nam 5,5 ± 2,9
Thcri gian dau (thang) (n - 4) Trung
blnh
36 ± 2 3 Max/
Min
32/48
Oiem dau Trung binh Tuthe diing Tuthe nSm
Trudc nut mach (n = 4) 7,7 ±1,5 7,9 ± 2,1 5,5 ± 2,9
Sau nut mach 6 t h a n g
(n = 4) 2,6 ± 2,5 3,1 ± 2,7 2,1 ± 2,5
iUluTcy nghia p
<0,001
<0,001
<0,001 Whdn xef; Thang diem dau trung binh trudc nut la
7,7 ± 1,5. Thdi gian dau trung binh cCia b i n h nhan la 36 t h i n g , benh nhan ed thdi gian dau lau nhat la 48 t h i n g .
Nhdn xet Thang diem dau sau nut mach d eac t u the dUng, nam deu giam so vdi trudc nut, mUe g i l m e d y nghTa thdng kevdi p<0,001.
3.3. DUdng kinh tfnh mach buong trdng trai 4 . Ban l u d n trU&c mit tren CL VTmach mau va DSA
Biing 3. DUdrng Icinh t i n h mach b u d n g t r u l i g t r a i t r u d c n u t t r e n CLVT, MRI mach m a u va DSA
IVIRI, CVLT (mm) Trung blnh
(n = 4)
10,1 ±3,5 Min/Max
10/15
DSA (mm) Trung binh
(n = 4) 12,2 ±5,1
Min/Max
11/19 Nhdn xet £)Udng kfnh trung binh tTnh mach budng trUng trai tren CLVT nhd han t r i n DSA.
3.4. T^le thanh cong va bien chdng
Bang 4 . Ty le t h a n h c o n g , bien c h i h i g S6 bSn can t h i ^ p
Ben phai 0
Ben trai 4
Hai ben 0
T ^ l e thanh cong(%)
100
T^ le bien chuing (%)
0
Nhgn xet Tat ea 4 benh nhan deu dUpc can thiep gian tTnh mach tinh b i n t r l i . Ty le thanh edng va 100% va khdng cd bien chUng xay ra.
Tudi trung binh cua benh nhan 33,5 ± 10,5 tudi trong d d cao nhat la 53 tudi, sd lan sinh con cua benh n h i n tUOng ddi eao trung binh I I 3,5 lan, dang ke ed b i n h nhan sinh tdi 5 l l n . Chua ed thdng k i nao ve sU lien quan giQa tudi va sd lan sinh eon vdi hdi chUng sung huyet tii'u khung. Tuy n h i i n mdt sd tac g i l tin rang tinh trang suy van tTnh mach cd the tang len trong q u i trinh mang thai nguyen n h i n do tang lUu lUpng ddng c h l y tTnh mach, tTnh mach budng trUng edn ed the thi de ep do trpng lUpng tU eung to, nhOng yeu t d t r i n gay ra tdn thuang cho mdt sd van tTnh mach [6]. NhU vay sd lan mang thai cang nhieu thi nguy co gay ra hdi chUng n l y cang tang. Ngoai ra mdt sd g i l thuyet ve n g u y i n nhan eCia hdi chUng nay da duac de cap den nhU yeu t d hormon hay sU vang mat cua mpt sd van tTnh mach gay ra.
V^ dudng kinh tTnh mach budng trUng trai trUde nut mach t r i n MRI, CLVT va DSA deu > 10mm, dudng kfnh t r i n MRI, CLVT nhd hon tren DSA, su khac b i i t nay do khi chup DSA chung tdi eho benh nhan lam nghiem phap Valsava lam tang I p lUe trong tinh mach than - tTnh mach budng trUng l l m cho tTnh mach budng trUng g i l n hon so vdi khi chup MRI, CLVT. Trong n g h i i n eUu ehung tdi deu can thiep gian tTnh mach budng trUng t r l i , bdi trong sd
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARIVIACY Vol.l2-N''4/2017
4 benh nhan thi tTnh mach buong trUng trai deu gian, tinh mach budng trdng phai khdng gian, so vdi mdt sd t i e g i l khae nhU Venbrux can thiep b i n phai hole e l hai ben [7], sU khae b i i t nay ed the do sU v^ng mat eua cac van tinh mach budng trUng ben
trai 15% va b i n p h l i 3% d phu nU trong mot so n g h i i n eUu ve g i l l phau, b i n canh dd sd lUpng benh nhan cOa bao eao ehung tdi ft n i n chua gap trudng hpp benh nhan ed gian tTnh mach budng trUng phii,
Anh 1. Binh nhan Pham Thi H A. Siiu am g i l n tTnh mach budng trUng t r l i .
B. CHT gian tTnh mach budng trUng trai
Ty le thanh edng eua ky thuat la 100%, tat c l ele b i n h n h i n deu dupe can thiep gian tinh mach budng trUng b i n t r l i , t^ l i thanh cdng trong nghien eUu ehung tdi eao han Pleri hay Maleux [6], [7]. SU khac biet ve ty le thanh cdng va sd ben can thiep cd the do sd lupng b i n h nhan cua ehung tdi chua nhieu n i n ehUa gap nhieu bien the eua tTnh mach budng trUng lam tang ty le thanh cdng. Vat lieu nOt gian tTnh mach budng trUng k h i gidng vdi g i l n tTnh mach tinh d nam nhU coil, chat gay xa, keo, hay bdng. Cho du vat lieu coil dUpc xem la h i i u q u i trong diiu tri gian tTnh mach budng trUng, tuy nhien van ed ty l i tai phat sau can thiep bang coil, nguyen nhan cd the lien quan den sU t l i thdng ele nhanh b i n da dugc mieu t l trong mdt sd b i o d o can thiep nut tae tinh mach tinh b i n g coil trong dieu trj gian tTnh mach tinh. Vat lieu chat gay xo bao gdm
Gelfoami hay keo cd the giup trao vao eae nhlnh bSn tranh tai p h l t . Tuy n h i i n cd nhieu bao d o v i tJ le bien chUng khi sCf dung rleng tUng vat lieu coil hay keo, Gelfoam don thuan, ele bien chUng cothe gap bao gdm coil hoac keo trao ve tTnh mach than, tinh mach phdi, va day chfnh la nguyen n h i n gly huyet khdi ddng mach phdi. T r i i u chUng lam sang c6 the gap la dau h o l e ho ra mau. Do dd ehung tdi da sO dung ket hpp coil v l keo (sandwich technique) de t i n dung uu diem eua eac vat lieu nay, diJng coil chan dau dUdi de t r i n h keo d? chuyen di xa, ben canh dd keo ed the lan vao c l e n h l n h ben tach latii tTnh mach budng trUng - nguyen nhan cd t h l gay tai p h l t sau dieu t n . Va k i t qua ban d i u eho thay rSng khdng cd bien ehUng x l y ra trong qua trinh nga) sau can thiep va sau can thiep 6 thang.
Anh 2. Benh nhan Do Thi Phuong A A. Chup tinh mach budng trUng trai g i l n trudc khi nut mach.
B. Sau khi ntit t i c b i n g coil v l keo Hystocryl
TAP CHf Y DL/OC LAM SANG 108 T|pl2-S64/2017
Trieu ehUng lam sang sau can thiep 6 t h i n g d :ac b i n h nhan deu giam rd ret, thang diem Vas :rung binh trudc nut tU 7,7 + 1,5 diem xudng edn 2,6 12,5 diem sau 6 t h i n g d i i u t n , sU khac b i i t nay ed y nghla thdng k i vdi p<0,001. Ket qua nay cung tuang Sdng vdi tae gia Kim b i o e l o 2006 tren 127 b i n h nhan [8]. Nhu vay so vdi mo m d e l t tCf eung - budng trUng hay md ndi soi thi nut mach cd nhieu Uu diem han bao g d m t h d i gian nam vien ngan, khdng p h l i gay me va trieu ehUng lam sang e l l thien tdt. Do d d nut tTnh mach buong trUng dieu trj hdi ehUng sung huyet dupe xem nhu la lUa chpn Uu t i i n .
Cho d i j trieu chUng lam sang cd c l i t h i i n d i n g ke tuy nhien trong bao eao cCia ehung tdi cung nhu t r i n the gidi ehUa ed t h d n g k i v i ehUe nang sinh due sau khi can thiep dupc tien hanh. Trong nhUng nghien cUu dai han vdi sd luang benh nhan Idn ban ehung tdi se de cap d i n van d i nay.
5. Ket l u a n
Oieu trj hdi chUng sung huyet tieu khung bang can t h i i p npi mach gay bit tac d i m rdi tTnh mach budng trUng la phuang p h I p an toan va hieu qua.
Tat lieu t h a m khdo
1. RobinsonJC (1993) Chronic pelvic pain. Curr Opin Obstet Gynecol 5:740-743.
2. Park SJ, Lim JW, Ko YT et al (2004) Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. /UR Am J Roentgenol 182:
683-688.
3. Umeoka S, Koyama T, Togashi K et al (2004) Vascular dilatation in the pelvis: Identification with CT and MR imaging. Radiographics 24:193-208.
4. Carter J {1998) Surgical treatment for chronic pelvic pain. J Soc Laparoendose Surg 2:129-139.
5 Venbrux AC, Chang AH, Kim HS et al (2002) Pelvic congestion syndrome (pelvic venous incompetence):
Impact of ovarian and Internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vase Interv Radiol 13:171 -178.
6. Pieri S, Agresti P, Morucci M et al (2003) Percutaneous treatment of pelvic congestion syndrome. Radiol Med (Torino) 105: 76-82.
7. Maleux G, Stockx L, Wilms G et al (2000) Ovarian vein embolization for the treatment of pelvic congestion syndrome: Long-term technical and clinical results. J Vase Interv Radiol 11: 859-864.
8 Kim HS, Malhotra AD, Rowe PC, Lee JM (2006) Embolotherapy for pelvic congestion syndrome:
Long-term results. J Vase Interv Radiol 17:289-297.
