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 (*) B(-nh vien Binh Ddn - TP. HCM
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CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGl/C VIET NAM deu. DUdng kinh trung binh nhdm mo sau nam
2000 la 55mm.
Ton thugng vi the: xd vCia thanh mach chiem 90%, viem va thoai hoa va khong viem, khong thoai hoa chiem 10%.
Chidinh dieu tri- Dieu tri va ket qua:
- Oieu tri npi va ket qua d 593 benh nhan: la nhij'ng benh nhan chUa co chi djnh mo hay tir choi mo va chi dinh mo khi tiii phinh Idn, doa vd hay gay bien chu'ng. Thudc dieu trj: Doxycycline lOOmg, Aspirine Bimg/ ngay. SA bung theo doi tiii phinh. Ket qua cho thay, ddi vdi nhom dUdng ki'nh ngang tiii phinh nho, dUdc theo doi, moi nam co 24% phai md do tui phinh Idn nhanh, nhat khi dUdng kinh ngang tiii phinh 30-40mm, khong co trUdng hgp nao t i i vong do v9 phinh.
Odi vdi nhom benh nhan co dUdng ki'nh tui phinh
>50 mm khong chju md hay chUa mo do nguy cd phau thuat cao, 36% phai md cap cu'u do vd phinh va tii vong ia 50%.
OUdng ki'nh tiii phinh d nhom benh nhan co dieu trj npi tang cham so vdi nhom khong dieu trj nhUng chUa co y nghTa thdng ke, nhat la d nhom phinh nho.
- Phau thuat va ket qua d 778 benh nhan do:
• OUdng ki'nh ngang tiii phinh > 40 mm d ntiva 45 mm d nam.
• Tiii phinh bj bien chiing nhU vd, dpa vd, ro vao tinh mach hay dng tieu boa; thuyen tac dpng mach chi, dpng mach tang; tiii phinh co Idng bi hep hay tac.
• Co dong mach tang, chau hay chau-diii bj tac, hep hay phinh Idn.
- Cai tien phau thuat kinh dien: Nhieu cai tien ky thuat dUdc iing dung cd hieu qua t i i sau nam 2000 nhU dUdng md bung nho, phau ti'ch tdi thieu dau tren va dau dUdi tiii phinh de chan mau, ghep ket hdp vdi tao hinh de xd dung dng ghep thang...
- Lfng dung ky thuat thich hdp va ft xam lan:
Oe djnh benh va chi djnh dieu trj, t i i nam 1995, MSCT 16 roi MSCT 64 da dUdc xii dung. 6 nhiJng trUdng hdp doa vS, SA Doppler mau la dii de mo cap cu'u. Oe dieu tri nhu'ng benh nhan co tiii
phinh Idn phu hdp ma phau thuat kinh dien co nguy cd cao, mpt sd da dUdc dat stent-graft. Noi soi ghep DMC cung da bat dau cho 1 so tru'dng hdp chpn Ipc.
Bien chu'ng chung la 33.4%; t i i vong phau thuat Chung la 8.7% (2.5% mo ke hoach, 35%
mo cap ciru). Oa sd bien chiing va tii vong do mat mau nang vi v5 tiii phinh dan den rdi loan dong mau, ha huyet ap roi suy da tang.
Theo doi trung binh 5 nam (tii 6 thang den 18 nam), 11.2% benb nhan cd bien chiihg lien quan den phlu thuat va ong ghep vdi 1.5% tir vong d nhijUg benh nban md lai. Ciing thdi gian tren, co 3% benh nhan phinh dong mach cbii mdi phai mo va ft nhat co 2 benh nhan phinh tai phat d dau tren dng ghep.
Ban luan : Phinh dpng mach chii bung la benh thudng gap d nam, tren 50 tudi. Cung nhif cac nghien ciiu qudc te, xd vu'a thanh mach chiem 90%. Ve dac diem djch te, lam sang va can lam sang cd sd diem khac biet nhU phinh do viem nhiem gap nhieu trong nhdm benh nghien ciru ciia chiing toi. Chan doan khong kho, da so
•phat hien dUdc khi kham bung va sieu am.
V6 phinh la bien chirng rat nang, ty le tu' vong rat cao, ke ca khi phau thuat kjp thdi. Vdi nhu'ng tui phinh >45 mm, nguy cd vd Idn, nhat la d nhu'ng ngUdi hiit thudc la va cd benh phoi man tfnh. Cao huyet khong dieu trj tdt cung lam cho till phinh Idn nhanh va vd.
Trir nhij'ng trUdng hdp cd bien chu'ng, nhat la vd hay dpa v3, khi tiii phinh hinh thoi co dudng kfnh ngang < 45 mm chi nen theo doi dinli ky, neu > 45 mm thi cd chi djnh mo. Tat ca till phinh dang tiii > 30mm deu phai md. Chiing to! du^ ra chi djnh nay va iing dung tii nam 2000 da lam giam dUdc ti le vd phinh phai md cap ciiu ia 10%.
Nhieu cai tien ky thuat md kinh dien dUdc Ling dung co hieu qua tir sau nam 2000 nhii dudng mo bung nho, phau tfch tdi thieu dau tren va dau dudi tui phinh de chan mau, da sd diidc ghep va tao hinh vdi dng thang (72%), 5% phai cam lai dpng mach mac treo trang dUdi. 1/3 benh nhan phai mo cap ciru. Nhd cai tien ky
312
YHOC VIET NAM SO DAC BIET - THANG 11/2010 '• thuat, phau thuat trd nen ddn gian d benh nhan
'^ mo ke hoach nhUng md cap ciiu do vd phinh, ' van de kho la lam sao chan dUdc mau chay cang
sdm cang tot de hoi siic, dieu tri soc mat mau cung ' nhU roi loan dong mau hieu qua mdi mong cuU sdng
• dUdc benh nhan.
'i Tii nam 2005, chung toi da khdi sU dat
• stent-graft cho mpt sd benh nhan co nguy cd mo md cao va ghep dpng mach chii bung-chau qua npi soi 6 bung d mpt so trUdng hdp chon Ipc.
: Ket luan : 6 Viet Nam, 90% phinh dong
; mach chii bung la do xd vu'a thanh mach. Phinh DMC do viem chiem 1 ti le cao
Djch te hpc, benh canh lam sang va can lam sang co mpt sd dac diem rieng.
Tir nam 2000, chi djnh dieu trj thi'ch hdp da cai thien tien lUdng:
- Oieu trj npi va theo doi nhij'ng tiii phinh nho, chUa co trieu chirng.
- Mo ke hoach 6Mc chi djnh vdi dUdng kfnh tui phinh tir 40- 45mm.
95% dat ket qua tiic thdi va lau dai tdt d nhQ'ng trUdng hdp md ke hoach nhUng md cap ciru till phinh vd, bien chu'ng va tir vong van con rat cao.
I^pt sd ky thuat dieu trj phinh OMC ft xam hai dUdc img dung trong nhuTig nam gan day da dat dUdc nhQng ket qua rat khi'ch le.
ABSTRACT
PROGRESS IN TREAHNG THE AAA OF VIET NAM Background: AAA is a vascuiar disorder of the elders. Rupture of AAA is a lethal risk
Objective: To find the progress of treatment of AAA in studying:
- The epidemiology and the clinical characteristics.
- An appropriate therapeutic indication for reducing the rate of AAA rupture:
1. A medical treatment and a plan of follow- up are studied.
2. A surgical intervention with modified techniques for reducing the complications and death are applied.
3. The minimally invasive surgical techniques are started.
From the results, a recommandation may be proposed.
Materials and method: Prespectively, all AAA treated at Binh Dan hospital from 1991 to June 2010 are studied. The progress of diagnosis, of therapeutic indications, of modified surgical techniques and of minimally invasive surgery have been evaluated.
During this period, 1335 patients of AAA are admitted and treated in our hospital that 778 patients having had surgical intervention and 593, medical treatment.
Results:
Epidemiological, clinical data:
Male/female: 4. Middle age: 74. 18% of cases > 80 yo, 5.5% < 30 yo. 56% had heavy smoking with no special remarks about nutrition, social classes and geographic distribution.
More than a half of AAA have had a high blood pressure. 100% of AAA have had an abdominal pulsative mass.
20% of AAA have had an acute or chronic ischemia of one or two lower limbs.
Labo data:
- On blood tests, there are 35% of patients having had a cholesterol > 2,4g/l, 2% VDRL positive, I, 9% glucose > l,4g/l, 12% creatinine
>100mg/l. 42% having had at least 1 abnormal line on EKG
- On Doppler US: 37% abnormal heart function or heart valve, 12% mild or advanced stenosis of the carotids, 7% mild or severe stenosis of the renal arteries, 36% aneurysmal wall dissecting (or fissuring), retroperitoneal rupture or free rupture, 22% associated aneurysm of iliac arteries, 17% substenosis of iliac arteries and 4 1 % , the aneurysm lumen reduced by clot.
- On arteriographies (DSA), Cl or MSCT:
There are extensions of aneurysmal sac above the left renal artery in 12%, the aneurysmal sac lay on the left side of the umbilicus in 58%,
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CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGLTC VIET NAM almost have had an irregular sac wall with a
median diameter, 55 mms.
- 2 groups of pathologies are found:
atheromatous lesions: 90%, inflammatory and degenerative lesions and non inflammatory, non degenerative lesions: 10%.
As progress imaging for diagnosis, since 2000, we use color doppler US for the emergency cases and MSCT-64 for the elective cases.
Indications of treatment:
Therapeutic results: Medical treatment and follow-up of small asymptomatic aneurysms (D <
45 mms), surgical treatment for the remainings (D > 45 mms) and for the cases having had complications (rupture, threaten rupture ...)
- For 593 patients follow-up with medical treatment: Doxycycline lOOmg and Aspirine Bimg per day, the results as follow: for the group of aneurysm 30- 40 mms, 24% must be operated each year and nil died due to aneurysm rupture but for the group of patients having aneurysm > 45mms, who deny surgery or have had very high surgical risk, 36% must be operated in urgency by rupture with 50% death.
On 2005, a RT study of medical treatment for 141 patients with a follow-up 12 month, the preliminary results showed that there are a slow growth of aneurysmal sac.
- Surgical indications and results for 778 patients:
Modified surgical technique: a small abdominal incision, a minimal dissection to control the aorta and the iliac arteries, a straight tube graft with plasty in 72% of cases are applied.
New techniques applied: Stent-graft performed for 4 cases and laparoscopic repair of AAA for 3 cases.
As surgical results, 33.4% complications and 8.7% mortality are registed: (2.5% of elective, 35% of emergency cases). All the complicated and the death cases related to hemorrhagic shock, bleeding by coagulation defect, hypotension, cardiac, respiratory, renal problems leading to MOF.
In the follow-up average 5 years (3 months- 18 years), 11.2% complications and 1.5% death relating to prothese and grafting procedure are noted.
In tiie same time, 3% of new aortic or iliac aneurysms developped and at least, tiiere are 2 cases of aneurism developping above the graft.
Discussion: AA is a disease of the elders, usually men, almost are over 50. Arteriosderosis is main pathology. The diagnosis is not difficult with AAA, uncomplicated. A good US data solderly, enough to give diagnosis and therapeutic indications.
The deadly risk of AAA is rupture of aneurysm sac, especially when its diameter
>45mms.
For the asymptomatic AAA < 45mms, it is safe to follow up each 3-6 month by US and to have a new therapeutic indication.
Elective surgery is not difficult, safe and effective for the AAA below the renal artery. But for the ruptured aneurysms, to stop bleeding and to reanimate before repairing the aneurysm is crutial.
In the recent years, we start to perform the AAA repair by a small abdominal approach w/ith a lot of modified surgical techniques. An AAA laparoscopic repair and an intraluminal stent- graft are also practiced successfully.
Conclusion: In Viet Nam, 90% of the AAA related to arteriosclerosis.
The epidemiology, clinical and paradinical characteristics have had their particularities.
Since 2000, morbidity and mortality reduced a lot by a modified therapy;
- A medical treatment and closed follow(-up for the small asymptomatic AAA.
- An elective surgical indication for the aneurysm 40- 45mm,
As results of elective AAA repair, ifs excellent but for the rupture one, it's still hasardous.
Some minimally invasive techniques as stent-graft or laparoscopic repair applied in our hospital got good results.
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