PHONG DANG TUI QUAI DONG MACH CHU VA DONG MACH CHU NGUC:
DENH LY NGOAI KHOA PHUfC TAP
Doan Quoc Hung*, Hoang Van Cong**
Vu Ngoc Tu*, Nguyen Hihi iTfrc*
TOM TAT
Phdng dang till qua! DMC va DMC ngUc hiem nhUng rat nang. Bao cao phan tich 11 BN da dieu trj vi benh nay tai Bv Viet Dii'c tii" 8-2008 tdi 11- 2009, gom 8 nam, 3 nii', tudi trung binh 60 (38- 72t). 3 BN dieu tri ngi va 8BN md. Ly do vao vien: dau ngUc (9BN), ho, khd nudt, kho ndi, khd thd, sdt keo dai (3BN), Scanner, MRI cho ket qua phong nhieu tui 5BN. ThUdng ton tai quai 5BN, sau DM dudi don 4BN va doan cudi DMC ngUc 2BN. Hgi chu'ng nhiem trimg chi gap d 2BN. Tang huyet ap 5 BN, hep mach vanh da nong IBN, PDMCB IBN va ung thU than IBN. 2BN tii chdi md, IBN tii vong dem ngay trUdc md. 4BN md vdi tim phdi may thay quai DMC, 4BN cau ndi tam thdi nach diii thay doan (2BN) va va mach (2BN) DMC xudng. Tii vong 4BN: 1 BN loc DMC tai cho dat Clamps, IBN buc mieng ndi sau md 4 tuan, 2BN suy da tang. IBN liet hai chan hoi phuc.IBN ket qua cay VK tu cau vang. Phong DMCN dang tiii ty le tir vong cao, nguyen nhan nhiem triing luon dUdc dat len hang dau tuy nhien de chu'ng minh lai khong de. Cac van de can giai quyet: can lam nhiing xet nghiem vi khuan nao, chien lUdc dieu tri ra sao: co hay khong tim phdi may, tUdi mau nao chgn Igc hay ha than nhiet sau-ngiing tuan hoan, vai trd ciia cau ndi nach-diii, vi tri ciia ngi mach mau trong tUdng lai?
ABTRACT
True saccular aneurysm of the aortic arch and descending thoracic aorta: a rare and
complicated pathology
Objective: A true saccular aneurysm of the
* Khoa PT Tim Mach Bv Viet Diec
thoracic aorta is extremely rare but particulaiy grave. This study present our experiences through a series of 11 patients treated at our institute from 8/2008 to 11/2009.Patients and Methods: There were 8 men and 3 women with ages ranging from 38-72 (mean 60 years old). 8 patients were operated and 3 medically treated.
Chief complains: chest pain 9 patients, coughing 5 patients, dysphagia 6 patients, dysphonia 7 patients, shortness of breath 3 patients, long- lasting temperature 3 patients. Exploration preoperation (TDM,MRI) showed a multiple saccular aneurysm of the thoracic aorta in 5 patients and single saccular aneurysm in 6 patients. The lesion located at the aortic arch in 5 patients, at the aorta under the left subclavian artery in 4 patients and at the last portion of the descending thoracic aorta in 2 patients.
Laboratory data found a infectious syndrom with hyperleucocytosis in only 2 patients and renal faillure in 2 patients. The serology (HIV, HbsAg, HCV, VDRL) was negative. Risk factors: arterial hypertension 5 cases, coronary angiography- stenting 1 patient, abdominal aortic aneurysm 1 case and renal carcinoma 1 case.Result: 2 patients refused to be operated, 1 patient died at night just before the operation (aneurysm ruptured). 8 patients operated: 4 cases with cardiopulmonary bypass (CPB) to replace the aortic arch, the temporary axillo-femoral shunt was used in 4 patients (thoracic graft 2 patients and lateral patch 2 cases). Operative mortality: 4 patients (50%) caused by aortic arch dissection 1 case, anastomotic rupture resulting from local-
Y HOC VIET NAM SO DAC BIET - THANG 11/2010 recldlve Infectious process at 4* week after
operation, 2 patients with multi-organ-faillure. 1 patient presented a paraplegia which completely regained. Only 1 patient showed positive with staphylococcus aureus on hemoculture.
Conclusion: Saccular aneurysm of the thoracic aorta is a lethal pathology and very difficult to be resolved in Viet Nam. The infectious cause is always suspicious (in multiple saccular form especially) but quite not easilly to be proved. The precocity of the diagnosis and treatment contribute an important role for the prognosis.
This complex disease propose, for us- the Vietnamese surgeons, a lot of questions: which kind of bacteriologic exam have to be done to detail the microbe? Which therapeutic strategy will be suitable and safe, with or without CPB, temporary axillo-femoral shunt or not, hypothermia-circulatory arrest or selective cerebral perfusion? And which is the position of endovascular intervention for this lesion in the future.
I. OAT VAN OE
Phong dong mach chii nguc dang tui (PDMCNDT) la benh ly khong thudng gap.
Nguyen nhan dugc ndi den nhiSu nhk la do chan thuang, nhiem triing hay phoi hop vai con ton tai ong dong mach hay hep eo DMC.
Mac dii d\hu tri PDMCNDT dugc de cap tir
rat lau, tuy nhien vdi nhirng truong hgp tiii phong ldn, tiii phong gay tdn thuang quai DMC thi viec chan doan va dilu tri vln la mot thach thirc doi vai phau thuat vien tim mach. Bao cao nay trinh bay 11 trudng hgp phong dang tiii (mgt hay nhiiu tiii) quai DMC va hoac DMC xudng da dilu tri tai khoa phau thuat tim mach benh vien Viet Due nham phan tich dac dilm lam sang, phuang phap chan doan va kho khan trong can thiep ngoai khoa loai benh ly nay, dilm lai y van nham cai thien kit qua dilu tri benh ly phong DMC nguc.
II. OOI TUONG VA PHUONG PHAP NGHIEN CGU Nghien ciiu hoi cim, tap hgp benh an cac benh nhan (BN) phdng quai DMC va DMC xuong dang tiii dugc chan doan va dieu tri tai khoa phau thuat tim mach benh vien Viet Due tir 8/2008 tdi 11/2009, phan tich nguyen nhan (nhiem triing, vii'a xa, hep eo DMC, con ong dong mach), chan doan lam sang (sot, dau nguc, kho thd, ndi khan, cat ldp vi tinh CT, cong hudng tii' MRI) va ket qua dieu tri (dieu tri ngi, mo co diing hay khong diing tuan hoan ngoai ca the), tir do rut ra nhan xet ban dau ve dac diem benh ly va phucmg huang dieu tri loai hinh thucmg ton nay trong dieu kien Viet Nam hien nay.
III. KET QUA
1. Phan bo 11 BN gom: 8 nam (72,7%), tudi tir 38 din 72 (trung binh 60). Chi co 2 trudng hgp lam ruong, con lai la cong chiic nghi huu, 10 BN song tai thanh pho.
Bang / : Ly do vao vien Ly do vao vien
Dau tiic nqUc*
Oau dudi sUdn trai Kho thd
Noi kho, noi khan Kho nudt
Ho keo dai Sdt keo dai
SdBN 9 1 3 7 6 5 3
Ty le % 81,8
9,1 27,3 63,7 54,6 45,5 27,3
''Dien hinh dau viing trudc tim hoac dau ca hai ben nguc, dau sau lim^
Bang 2: Tien sir benh
Tien su* benh Benh nhiem triing:
Chan thUdng Tang huyet ap
Benh mach nao Hep dpng mach canh Benh mach vanh:
Benh mach mau ngoai vi Phong DMC bung Hep dpng mach than Rdi loan chuyen hda md Rdi loan chuyen hda dUdng Benh ac tinh:
U phi dai tuyen tien liet
SdBN
2 BN dieu tri nhiem trimq phoi 0
6 1 nhoi mau nao
1
IBN da nong va dat Stent 0
1 1 4 1
1 (cat than trai do ung thU) 2
Ty l e %
54,6
36,3
2.Trieu chung lam sang luc vao vien
* Dau hieu nhiem triing gom: Sot (3 BN); Bach cau tang (6BN); Mau lang tang:
(4BN); CRP tang: 4 trtidng hgp CRP tang cao/ 9BN co thir CRP.
* Tran dich mang phoi trai: IBN
* Suy than (ure mau, creatinin mau tang): 0 BN
* Xet nghiem vi khuan deu am tinh: HIV
(II/IIBN); VDRL (9/9 BN); HBsAg (11/llBN) ngoai trir 1 trucmg hgp HCV duong tinh (/IO BN co thii).
3.Chan doan hinh anh:
Hinh anh khoi hk thudng tren XQ nguc: 11 BN Scanner: IIBN; Cat lop vi tinh da day MSCT: 9BN; Cong hudng tir (MRI): 3BN
Chup mach mau (Aortography): IBN;
Sieu am tim: IIBN
4.Vi tri va hinh thai thiroTig ton i Bdng 3: Vi tri -tinh chat thuang ton (N=l 1)
Vi tri-Tinh chat Quai DMC
DMC xudng
ThUdng tdn nhieu tiii
SdBN 5 6 5
Ty le % 45,5 54,6 45,5 5. Xir tri
Bdng 4: Cac phuang phap phau thuat (n*= 8) Loai hinh can thiep Loai phau thuat
DUdng md
Cap cii'u Co chuan bi Dpc xUdng irc NgUc trai sau ben
SdBN 0 8 3 5
Y HOC VIET NAM SO DAC BIET - THANG 11/2010 Tuan hoan ngoai cd
the
Co
Khong diing Cau noi nach-dui tam thdi
Cach thiic siia chii'a
Chay toan bp Khong liet tim
Thay quai DMC Thay doan DMC xudng
Md phong- Va ben DMC
3 1 4 4 4 2 2
* Da phlu thuat: 8BN; 2 BN tir choi mo xin dieu tri ngi; 1 BN c6 chi dinh mo nhung tir vong ngay dem trudc mo
6. Bien chung:
* M6 lai 2 BN: IBN sau md thay doan DMC 8 ngay, hon me. CT kiem tra phat hien 16c quai va ldc dgng mach canh, mo lai thay quai DMC. BN tir vong sau 24gid trong benh canh suy da tang. IBN sau mo thay doan DMC nguc 4 tuan, sot va khd thd, CT kiem tra thdy khoi gia phdng mieng noi DMC nguc CO thoat thuoc can quang ra khoang mang phoi trai. Mo lai vao khdi phong chay mau khong cam dugc. BN tir vong ngay tren ban.
* Liet chi dudi: IBN
* Suy than phai tham phan phiic mac:
2BN
* Xep phdi (phai soi hiit phe quan): IBN
* Md khi quan: 2BN
* Cay mau duang tinh (Staphylococus):
IBN
7. Tii' vong: 4 BN trong do 3 BN do suy da tang, 1 BN do chay mau trong mo.
8. Giai phau benh (7/8BN): 4 BN thuang ton thoai hoa, vila xa thanh mach, 2BN ton thuong viem khong dac hieu, IBN benh pham chi gom td chirc mau cue xam nhap bach cau da nhan
IV. BAN LUAN
1. Tinh thuong gap va benh can
Phdng dgng mach chii nguc (PDMCN) chi chilm khoang 15-20% PDMC ndi chung.
Cw nhie lai phong that (true aneurysm)
nghia la khi thanh tiii phong dugc cau tao bdi
dii ca 3 ldp ao thanh dgng mach, con gia
phong (false aneurysm hay pseudoaneurysm)
la khi thanh tiii phong khong con dii 3 ldp ao
thanh mach. Ve dai the chia lam hai loai
phong dang thoi (fusiform) khi tiii phong
phat trien deu theo toan bg chu vi thanh
mach, va phdng dang tiii (sacciform) khi tiii
phong phat trien uu the ve mgt phia thanh
mach. Da phin phong DMC dii d vi tri nao
(DMC len, DMC xudng, DMC bung) chii
ylu van la phong dang thoi, vdi nguyen nhan
ca ban la viia xa dgng mach hay benh thoai
hoa ldp ao giira (hgi chung Marfan), hoai tir
tl bao ao giiia (cystic medial necrosis,
thuong phoi hgp vai ton thuang ca DMC len
va quai DMC). Ty le phdng dang tiii ciia
DMCN khong nhilu, mac dii da dugc de cap
din tir rk sam: Kampmeier thong bao loat
633 BN PDMCN dang tui dang tren tap chi
ngi khoa tir nhtmg nam 1938. Tai khoa phau
thuat tim mach benh vien Viet Diic, trung
binh moi nam chimg toi gap khoang 50
trudng hgp phong DMC, trong do co khoang
PDMCN. Tuy nhien chi trong thod gian 15
thang (8/2008 tdi 11/2009) chung toi da gap
tdi 11 BN phdng dang tui ciia quai DMC va
DMC xudng (tren tdng s6 PDMCN). Khong
kl cac truong hgp gia phong dang tui DMCN
sau chin thuang hoac sau mo ghep mach
nhan tao (gia phong mieng noi), nguyen nhan
phong that dang tiii DMCN van thudng dugc nhac den trong y van la hep eo DMC, nhiem triing. Nhiem trimg co the la nguyen phat, co thi la thu phat tren mgt tui phong da ton tai tir truac. De chan doan chinh xac nguyen nhan nhiem triing khong phai liic nao cdng thuan lgi. Y van de cap tai nguyen nhan thuang ban (Salmonella), giang mai, phe cau (Streptococcus pneumoniae), tu cau (Staphylococcus aureus), lao, tham chi ca E.Choli [7]. Trong 11 BN ciia chiing toi chi CO 2 trudng hgp co the khang dinh nguyen nhan phong la do nhiem triing (vdi cac dau hieu nhiem triing ro va keo dai tren lam sang, tuy nhien ciing chi IBN cay mau tim thay vi khuan, Staphylococcus, phai chang do benh nhan trudc khi den vai chiing toi da dugc dieu tri nhieu loai khang sinh manh keo dai 1-2 thang??). Cac nhiem triing dac hieu nhu lao, giang mai ciing da dugc chimg toi thuc hien he thong, tuy nhien khong lan nao phat hien dugc. Van de can thao luan d day la dung trudc truong hgp phong dang tui DMCN, cac xet nghiem vi khuan nao can phai dugc thuc hien mgt each he thong, hay la chi thuc hien lira chgn tren ca sd lam sang CO dau hieu nghi ngd? Cac xet nghiem thong thudng nhu Mantoux, BW, VDRL, Widal lieu cd dii hieu lire de phat hien benh hay khong? Hay phai thuc hien cac phan img dac hieu nhu TPI (Treponema Pallidum Immobilisation: phan ung bat dgng xoan khuan), FTA (Fluorescent Treponema Antibody: phan iing khang the xoan khuan huynh quang), TPHA. Theo Yokoyama, Wen Chu, hay Rafael Marques da Silva, de tim thay dugc vi khuan trong cac trudng hgp nghi ngd phai dimg cac phuang phap nhuom dac biet (polymerase chain reaction PCR) va soi duod kinh hien vi dien tir, va bang cac bien phap nay co the tim thay dugc 72%
ngudn nhilm khuin [8]. Hien nay tai Benh vien Viet Dire chimg toi chua thuc hien duoc cac tham do nay.
*/Cac xet nghiem danh gia tinh trang nhiem triing: bach cau tang (6/1 IBN), mau ling tang 4BN, CRP tang 4/9BN c6 thir. CSy mau truac mo thuc hien cho 2 BN trong do 1 trudng hgp duong tinh tu cau vang, cay mau sau mo 3 BN deu cho ket qua am tinh.
Malouf nhan xet rat kho tim thay vi khuin trong mau d nhiing trudng hgp PDMCN nhiem trimg.
2. Chan doan
2.1.Ldm sdng: Cac dau hieu lam sang khien berth nhan vao vien rat khac nhau [Bang I], tuy nhien vi tiii phinh nam 6 vi tri quai DMC va DMC xuong nen co cac dau hieu tuong doi dac hieu nhu dau tiic nguc (9BN), noi khan (7 BN), khd nuot (6BN), khd thd (3BN), ho keo dai (5BN), dac biet khi CO nhieu tui phinh va cac tui phinh nam is vi tri bd cong lom cua quai gay ehen ep than kinh quat ngugc, ehen ep khi phe quan va cben ep thuc quan. Khd nuot do nguyen nhan mach mau (dysphagia lusoria) kinh dien la do bat thuong dgng mach duai don chay phia sau thuc quan. 6 trudng hgp kho nuot cua chiing toi co 4 BN da dugc soi da day-thyc quan phat hien thuc quan bi de ep tir ben ngoai, thudng a miic 22-25 cm tir cung rang tren, khong cd trudng hgp nao phai chup uong Baryte. Irfan thong bao 1 BN kho nuot do ehen ep thuc quan bdi khoi phinh dang tui DMC xuong [10]. Tham chi c6 BN vao vien vi ngat thd cap- tit vong (acute fatal asphyxia) do phong nhieu tui quai DMC ehen ep vao khi quan va phe quan goc trai [9].
Chiing tdi co 1 BN cam giac nang tiic day nguc trai, XQ va CT nguc phat hien khoi phinh DMC cben ep gay liet than kinh hoanh trai. Cac trucmg hgp khoi phong phat trien
Y HOC VIET NAM SO DAC BIET - THANG 11/2010
lau nam c6 thi dinh vao nhu mo phoi hay phe quan gay ho khac mau, nhit la khi khoi phong nhiem triing [7]. Day la cac ylu to gay kho khan va nguy hilm trong qua trinh phau thuat. Ciing co trudng hgp BN khong bieu hien diu hieu ca nang ro rang, chi cam giac nang tiic viing day nguc tiii phinh dugc phat hien tinh cd tren XQ hay CT nguc (chup vi ly do khac) hoac khi trong mo (mach vanh, van tim). Vi vay doi vdi BN co dau hieu bat thudng ve dudng ho hap, ndi, nuot.. can nghi tdi nguyen nhan benh ly phinh mach.
*/Sieu am qua thanh nguc la cin thilt, muc dich danh gia chuc nang tim, thuong tdn phii hgp (ca tim, van tim, DMC len, dich mang tim) va CO the phan nao danh gia thuang tin doan gin cua quai DMC. Vdi doan xa quai DMC va DMC xuong tham do sieu am qua thanh nguc ban che, CO thi thay thi bing sieu am qua thuc quan.
Doppler dgng mach canh, mach dudi don va chi dudi can thuc hien he thong nhim danh gia miic do lan toa thuang ton va du kien phlu thuat (dudng mo, phuang thiic thiet lap tuin hoan ngoai CO the CPB: Cardio Pulmonary Bypass).
2.2.Chdn dodn hinh dnh
*/100% BN trong nghien cuu diu phat hien hinh anh can quang bit thudng tren XQ nguc thang (trung thit tren gian rgng, de diy khi quan, tran dich mang phdi, liet ca hoanh trai). C6 the thay hinh anh voi hoa thanh tiii phinh. Dilu ghi nhan d day la tit ca BN cua chiing toi khi vao vien diu co cac khdi phinh kich thudc ldn, nghia la da qua mgt thdi gian phat trien tuong ddi lau. Vi vay chi cin kilm tra dinh ky XQ nguc, nhit la vdi nhom BN nguy ca la ciing co thi phat hien dugc sdm cac trudng hgp PDMCN.
*/CT Scanner, dac biet la cat ldp vi tinh
da day (MDCT: Multi Detector CT) dugc cac
tac gia thong nhat la tham do quan trgng va
him ich do tinh it xam lan, danh gia chinh
xac vi tri, mile do thuong ton tren toan bg
cay DMC va cac nhanh (chiing toi phat hien
I BN CO phong DMC bung, IBN ldc dgng
mach canh chung trai), lien quan vai tang lan
can (khi phe quan, thuc quan, phoi). Ngoai ra
cdn de kiem tra sau mo va theo ddi lau dai.
Hinh 2: MDCT trudc mo: phinh nhieu tui quai DMC
Hinh 3: MDCT sau mo: cat tui phinh ghep doan DMCN sau DM canh chung trai
Ca 11 BN trong nghien cim chiing tdi deu dugc chup CT thudng, va 3BN chup MRI (deu d tuyen trudc), sau do 9/1 IBN da dugc chup lai MDCT xac dinh chan doan.
Nhu vay neu tren XQ co hinh anh bat thudng nghi ngd phinh DMC thi nen chup MDCT ngay tranh lang phi tien bac va thdi gian.
*/Chup DMC (Aortography) chi dugc thuc hien d IBN, khi can thiet phai danh gia thuang ton phoi hgp d mach nho (mach vanh, mach tang). Hien nay vod ky thuat tai lap hinh anh bang AngioScan va MDCT hiem khi phai thuc hien chup mach mau (la tham do chay mau)
2.3. Chdn dodn benh phoi hgp vayeu to nguy eff [Bdng 2]
* Vila xa dgng mach, roi loan chuyen hoa ma xac dinh tren 4BN, tang huyet ap 6BN va 1 BN da co tai bien nhoi mau nao, hep mach canh IBN, hep dgng mach than IBN va I BN da nong-Stent mach vanh. Nhu vay ro rang mgt so lugng BN khong nho tuy c6 phinh hinh tui ciia DMCN, co cac yeu to nguy ca vira xa va idiong chung minh dugc nguon goc nhiem triing. Mac dii nhieu tac gia dong nghTa thuang ton phinh dang tiii DMC la do nhiem triing: 93%o theo Thanila, 60%
theo Dylan [8], nhung thuc tl nghien ciru
chiing toi khong hoan toan nhu vay.
Y HOC VIET NAM SO DAC BIET - THANG 11/2010
* 1 BN da cit ung thu than trai (la ly do khiln BN tir chdi can thiep phlu thuat PDMCN), IBN u phi dai tuyln tiln liet. IBN tilu dudng.
3. Dieu tri
3.1. Chidinh: cin thing nhat rang khi da chin doan phinh dang tiii DMCN dii do nguyen nhan nao thi ciing phai can thiep cang sdm cang tdt, tranh bien chiing vd, 16c thanh, tic mach, ehen ep hay do vao tang lan can. Tuy nhien trong 11 BN cua chiing toi co 2 trudng hgp BN tu chdi mo va 1 truong hgp tir vong ngay dem truac mo (do va tiii phinh)
3.2. Md md, phdu thudt npi soi hay can thiep npi mgeh?
Mot so tac gia chii truang sir dung ky thuat noi mach mau doi vdi phong nhiem tning DMC (nhit la DMC xuong va DMC bung) vdi ket qua ngan han-trung ban tot [5,6], tuy nhien so lugng BN trong cac bao cao nay khong nhieu. Han nQ'a phuang phap noi mach mau co cac ban che sau
+Kh6ng ap dung dugc vdi mgt so vi tri phinh d DMC len, quai DMC hay phinh sat vdi cac mach tang
+ Khong giai quyet dugc cac bien chung ciia tlii phinh (tui phinh to gay dau, ehen ep hay do vao tang lan can)
+ Khong lay dugc benh pham tir vo hay huyet khoi tui phinh xet nghiem phuc vu chan doan can nguyen nhiem khuan
+ Khong phai liic nao va d dau ciing ap dung dugc phuang phap nay do ban che ve trang thiet bi, phuong tien, nguod lam, chi phi (gap nhieu lan mo kinh dien).
* Phau thuat ngi soi (Coelioscopic Surgery): chua thiy c6 bao cap de cap tdi van de nay, nlu co chic ciing chi phii hgp vdi phong DMC xudng, vi ngoai uu the tham my thi phau thuat ngi soi vdi thuang ton phinh quai va DMC xudng chua that thich hgp.
chua ke den cac han che nhu: dung cu chuyen dung, thdi gian phau thuat keo dai Day la ly do vi sao cho den hien nay, phucmg phap nay chua dugc ap dung tai BV Viet Diic. Hy vgng trong tuang lai chiing toi co the ap dung cac ky thuat tien tiln nhu tren
3.3. Ky thudt md vd kit qud [Bdng 4]
*/ Chung tdi lira chgn mo vai tim phoi nhan tao (CPB) khi tiii phinh tai quai, kich thuac lon, nguy hiem neu phlu tich tui phdng tren tim con dap. Cach thuc thilt lap CPB tiiy thuoc kinh nghiem timg phau thuat vien.
Trong 8 BN phau thuat co 4BN mo vdi CPB ngay tir dau: 3 BN md xuong irc, CPB tudi mau chgn lgc mach nuoi nao, ha nhiet do 28°C, ngimg tuan hoan khi lam mieng noi xa va thay quai DMC, IBN CPB diii-diii, md nguc, ha than nhiet 20°C, ngimg tuan hoan (khong kep DMC, khong liet tim), thay doan DMC xudng. 2BN thay quai tit, con lai 2BN tir vong (1 do suy da tang, mot do nhiem triing phoi suy ho hap tha may keo dai)
*/ 4BN con lai dugc mo tim kin qua duong md nguc khoang lien suon 3-4 sau ben trai, trong do 3 BN dugc lam cau noi tam thdi nach-diii phai, phau tich khong che dau trung tam, thay doan DMC xuong 2BN, cat tlii phinh va ben DMC 2 BN. 1 BN duy nhit khong lam cau noi nach-diii, sau mo thay doan DMC, hon me keo dai, ngay thir 8 sau m l CT kiem tra thay 16c quai va dgng mach canh trai, mo lai vai CPB thay quai, tir vong sau m l 24 gid do suy da tang. Phai chang thuang tin 16c quai DMC la do BN khong co shunt nach-diii, nen phau thuat vien bi thuc bach vl thdi gian kep DMC. nen trong liic voi vang kep DMC da gay nen thuong ton 16c DMC duai clamps. 3 BN c6 dat shunt nach-diii khong truong hgp nao c6 bien chiing liet chi duai, tuy nhien IBN bien chung do mieng noi sau mo 4 tuan do nhiem
trimg, mo lai tir vong do chay mau ngay tren ban mo
* Liet hai chan IBN (thay quai, CPB toan bg, tuoi mau chgn lgc nao va chi dudi), nguyen nhan c6 le do thdi gian ngimg tuan hoan nira duod ca the trong khi lam mieng noi ngoai vi keo dai (47 phiit), nen mac dii da ha nhiet do 28°C, tuy van bi thieu mau. Tuy nhien tinh trang liet nay da hoi phuchoan toan sau 2 thang. Nhu vay riit ngan toi da thod gian thieu mau tang (chay may, ngimg tuin hoan, kep DMC) la can thiet, vi thuc su khd tien lugng hau qua cua viec thieu mau len cac tang nhu tuy, than, gan, rugt
* Suy than phai tham phan phuc mac: la bien chiing nang, nguyen nhan do benh than tir truac, hoac ngimg tuan hoan, kep DMC tren than, chay may keo dai. Can chii y tu the BN nam nghieng khong gay de ep vao shunt nach diii trong md.
* Cac bien chung hd hap: 1 BN xep phoi phai soi hiit phe quan, IBN viem phoi dieu tri ngi, 2 BN ma khi quan (tir vong): deu do BN tuoi cao chay may keo dai. Nhu vay viec riit ngan thod gian chay may, san s6c sau mo c6 vai tro quan trgng trong ban che cac bien chimg nay.
V. KE'T LUAN
Phong dang tiii quai DMC va DMC nguc la benh nang va khd dieu tri tai Viet Nam.
Nguyen nhan nhiem triing van la moi nghi ngd hang dau, tuy nhien viec xac dinh chinh xac lai hoan toan khong don gian. Chan doan sdm ngay tir khi khoi phinh c6 kich thuac con nho, chua c6 hien tugng xam lan tang lan can se lam cho phau thuat don gian ban nhieu. Mgt so khd khan chiing toi van chua c6 giai dap thau dao: de tim dugc vi khuan gay benh can lam nhiing xet nghiem dac biet gi; lira chgn phau thuat co hay khong diing
CPB, tuoi mau nao chgn lgc hay ha th§n nhiet ngimg tuin hoan, cau noi tam thdi nach diii CO thuc su lam giam bien chimg tuy, gan, than hay khong?? Trong tuong lai, ky thuat ngi mach mau hay ngi mach c6 the se co vj tri vod mgt s6 thuong ton nhat dinh, dac biet la doan DMC xuong.
TAI UEU THAM KHAO
1. Azmi Ozler, Ibrahim Arif Tarhan (2009), True saccular Aneurysm of the ascending aorta. The intemet Journal of Thoracic and Cardiovascular Surgery, 11,2: 1-3.
2. Bickford B.J, Glennie J.S (1960). Excision of saccular aneurysms of the thoracic aorta:
a report of five cases. Thorax, 15: 309-316.
3. Biglioli Paolo, MD, Rita Spirito, MD, Maurizio Roberto, MD, Alessandro Parolari, MD, Marco Agrifoglio, MD, Giulio Pompilio, MD (1995). False Hydatk Aneurysm of the Thoracic Aorta Ann Thorac Surg; 59:524-525
4. Bilgehan Savas Oz, Mehmet Yokusoglu (2009). Operation of coarctation with saccular aneurysm of descending aorta under support of low flow cardiopulmonary bypass. Anadolu kardiol Derg, 9: 248-252.
5. Brendan Stanley, Michael MD Lawrence Brown (2003). Endoluminal repair of mycotic thoracic aneurysms. J EndoVasc Ther 10,3:511-5.
6. Carmi D, Pellerin O, Labrousse L, Sapoval M (2009). Traitement des anevrysmes infectieux: chirurgie classique ou traitement endovasculaire? Les syndromes aortiques aigus. Springer Paris, 3: 227-234.
7. Clayton Davie.J (1963). Paraplegia from Compression Caused by Saccular Aortic Aneurysm with Recovery. Journal of Neurosurgery, 20, 11 ,
Y HOC VIET NAM SO DAC BIET - THANG 11/2010 8. Dylan Miller (2004). Surgical pathology of
infected aneurysms of the descending thoracic and abdominal aorta:
clinicopathologic correlations in 29 cases (1976-1999). Hum Pathol 35,9: 1112-20.
9. Elkettani C, R.Badaoui, P.Montravers (2003). Fistule aortobronchique a partir d'un
anevrisme infectieux de I'aorte thoracique.
Ann francaises d'Anesthesie et de reanimation, 22,2: 130-132.
10. Frikha I, Masmoudi S (2000). Anevrisme de I 'aorte thoracique compliquant une pseudo- coarctation. Archives des maladies du Coeur et des vaisseaux, 93,2:195-8
TIEN BO DIEU TRj PHINH DONG IVIACH CHU BUNG TAI VIET NAM
Van Tan, Ho Nam, Tran Van Quyen, Hoang Danh Tan, Ho Huynh Long, Nguyen Ngoc Binh, Ho Khanh Dij-c(*)
TOM LUOC
Phinh dong mach chii bung la benh mach mau ngudi nhieu tudi. Vd tui phinh la nguy o3 sinh tii.
Muc tieu nghien cu'u tien bp trong dieu trj phinh dpng mach chu bung qua cac mat:
- Dich te va dac diem lam sang de chan doan, chi djnh dieu trj va tien lUdng.
- Chi djnh dieu trj thich hdp de giam ti le vd tui phinh:
1. Oieu trj noi khoa va ke hoach theo doi 2. Phau thuat va cac cai tien nham giam bien chiing va tii vong.
3. Lfng dung cac ky thuat it xam lan hien dai de djnh benh va dieu trj.
Tii ket qua nghien cuU, nit ra mot sd khuyen cao.
Doi tu'dng va phu'dng phap: Tat ca benh nhan bj phinh dpng mach chii bung dieu trj tai BV Binh Dan tii nam 1991 den het thang 6, 2010, la nghien ciiu tien cuTu ca lam sang. Nhtitig tien bo ve cai tien ky thuat kinh dien va nhQ'ng phau thuat ft xam lan iing dung dUdc ghi nhan va phan tich
Ket qua: 1335 benh nhan dUdc nghien ciiu, trong do cd 778 benh nhan phai mo ghep, 593 benh nhan dieu tri noi va theo doi.
Dich te, dac die'm lam sang va can lam sang:
Sd benh nhan dieu trj tang dan hang nam. Ti sd nam/nu': 4/1. Tudi trung binh: 74. 18% >80 tuoi, 5.5% < 30 tudi. 56% hiit nhieu thudc la.
Khong cd gi dac biet ve dinh dudng, tang Idp xa hpi, gia dinh (trii mot sd benh nhan nff) va dja ly.
Tren 50% benh nhan co cao HA va mpt sd da cd bien chu'ng. 100% benh nhan cd khdi u bung dap va co dan be ngang theo nhjp tim.
20% benh nhan cd thieu nang tuan hoan viia hay nang d chi dUdi.
35% benh nhan cd cholesterol >2,4g/l, di kem vdi rdi loan chuyen hoa lipid mau; 1% VDRL (+); 9% dudng huyet >l,4g/l; 12% aeabnine
>100mg/l. 42% benh nhan co bat thUdng tren ECG.
Tren hinh anh sieu am Doppler mau, 37%
benb nhan co bat thUdng ve cd tim hay van;
12% cd hep t i i viia den nhieu dpng mach chii bung, 5% hep dpng mach canh; 7% hep viia hay nhieu dong mach than; 36% co tach npi mac, vd sau phiic mac hay vd tU do tui phinh; 22% cd phinh dpng mach chau; 17% hep dgng mach chau va 4 1 % mau cue kha day bam thanh tui phinh. Tren hinh CY hay I^SCT, 12% tiii phinh keo dai len ngang hay tren dpng mach than.
58% tui phinh lech trai. Oa sd co thanh khong
