TIN B IU TR PHNH NG MCH CH BNG TI VIT NAMVn Tn H Nam, Trn vn Quyn, Hong danh Tn, H hunh Long, Nguyn ngc Bnh, H khnh c Khoa-B mn Lng ngc-Mch mu BV Bnh Dn BV Bnh Dn, 371 in Bin Ph, Qun 3, TP H Ch Minh, Vit Nam E mail: binhdanhospital@hcm.vnn.vn Tm lc Phnh ng mch ch bng l bnh mch mu ngi nhiu tui. V ti phnh l nguy c sinh t. Mc tiu: Nghin cu tin b trong iu tr phnh ng mch ch bng qua cc mt: - Dch t v c im lm sng chn on, ch nh iu tr v tin lng. - Ch nh iu tr thch hp gim t l v ti phnh: 1. iu tr ni khoa v k hoch theo di 2. Phu thut v cc ci tin nhm gim bin chng v t vong. 3. ng dng cc k thut t xm ln hin i nh bnh v iu tr. T kt qu nghin cu, rt ra mt s khuyn co. i tng v phng php: Tt c bnh nhn b phnh ng mch ch bng iu tr ti BV Bnh Dn t nm 1991 n ht thng 6, 2010, l nghin cu tin cu ca lm sng. Nhng tin b v ci tin k thut kinh in v nhng phu thut t xm ln ng dng c ghi nhn v phn tch Kt qu: 1335 bnh nhn c nghin cu, trong c 778 bnh nhn phi m ghp, 593 bnh nhn iu tr ni v theo di. Dch t, c im lm sng v cn lm sng: S bnh nhn iu tr tng dn hng nm. T s nam / n: 4/1. Tui trung bnh: 74. 18% > 80 tui, 5.5% < 30 tui. 56% ht nhiu thuc l. Khng c g c bit v dinh dng, tng lp x hi, gia nh (tr mt s bnh nhn n) v a l. Trn 50% bnh nhn c cao HA v mt s c bin chng. 100% bnh nhn c khi u bng p v co dn b ngang theo nhp tim. 20% bnh nhn c thiu nng tun hon va hay nng chi di. 35% bnh nhn c cholesterol > 2,4g/l, i km vi ri lon chuyn ho lipid mu; 1% VDRL (+); 9% ng huyt > 1,4g/l; 12% creatinine >100mg/l. 42% bnh nhn c bt thng trn ECG. Trn hnh nh siu m Doppler mu, 37% bnh nhn c bt thng v c tim hay van; 12% c hp t va n nhiu ng mch ch bng, 5% hp ng mch cnh; 7% hp va hay nhiu ng mch thn; 36% c tch ni mc, v sau phc mc hay v t do ti phnh; 22% c phnh ng mch chu; 17% hp ng mch chu v 41% mu cc kh dy bm thnh ti phnh. Trn hnh CT hay MSCT, 12% ti phnh ko di ln ngang hay trn ng mch thn. 58% ti phnh lch tri. a s c thnh khng u. ng knh trung bnh nhm m sau nm 2000 l 55mm. Tn thng vi th: x va thnh mch chim 90%, vim v thoi ha v khng vim, khng thoi ha chim 10%. Ch nh iu tr- iu tr v kt qu: - iu tr ni v kt qu 593 bnh nhn: l nhng bnh nhn cha c ch nh m hay t chi m v ch nh m khi ti phnh ln, da v hay gy bin chng. Thuc iu tr: Doxycycline 100mg, Aspirine 81mg/ ngy. SA bng theo di ti phnh. Kt qu cho thy, i vi nhm ng knh ngang ti phnh nh, c theo di, mi nm c 24% phi m do ti phnh ln nhanh, nht khi ng knh ngang ti phnh 30-40mm, khng c trng hp no t vong do v phnh. i vi nhm bnh nhn c ng knh ti phnh >50 mm khng chu m hay cha m do nguy c phu thut cao, 36% phi m cp cu do v phnh v t vong l 50%. ng knh ti phnh nhm bnh nhn c iu tr ni tng chm so vi nhm khng iu tr nhng cha c ngha thng k, nht l nhm phnh nh. - Phu thut v kt qu 778 bnh nhn do: ng knh ngang ti phnh > 40 mm n v 45 mm nam. Ti phnh b bin chng nh v, da v, r vo tnh mch hay ng tiu ha; thuyn tc ng mch chi, ng mch tng; ti phnh c lng b hp hay tc. 1

C ng mch tng, chu hay chu-i b tc, hp hay phnh ln. - Ci tin phu thut kinh in: Nhiu ci tin k thut c ng dng c hiu qu t sau nm 2000 nh ng m bng nh, phu tch ti thiu u trn v u di ti phnh chn mu, ghp kt hp vi to hnh x dng ng ghp thng... - ng dng k thut thch hp v t xm ln: nh bnh v ch nh iu tr, t nm 1995, MSCT 16 ri MSCT 64 a dc x dng. nhng trng hp do v, SA Doppler mu l m cp cu. iu tr nhng bnh nhn c ti phnh ln ph hp m phu thut kinh in c nguy c cao, mt s c t stent-graft. Ni soi ghp DMC cng bt u cho 1 s trng hp chn lc. Bin chng chung l 33.4%; t vong phu thut chung l 8.7% (2.5% m k hoch, 35% m cp cu). a s bin chng v t vong do mt mu nng v v ti phnh dn n ri lon ng mu, h huyt p ri suy a tng. Theo di trung bnh 5 nm (t 6 thng n 18 nm), 11.2% bnh nhn c bin chng lin quan n phu thut v ng ghep vi 1.5% t vong nhng bnh nhn m li. Cng thi gian trn, c 3% bnh nhn phnh ng mch ch mi phi m v t nht c 2 bnh nhn phnh ti pht u trn ng ghp. Bn lun: Phnh ng mch ch bng l bnh thng gp nam, trn 50 tui. Cng nh cc nghin cu quc t, x va thnh mch chim 90%. V c im dch t, lm sng v cn lm sng c s im khc bit nh phnh do vim nhim gp nhiu trong nhm bnh nghin cu ca chng ti. Chn on khng kh, a s pht hin c khi khm bng v siu m. V phnh l bin chng rt nng, t l t vong rt cao, k c khi phu thut kp thi. Vi nhng ti phnh >45 mm, nguy c v ln, nht l nhng ngi ht thuc l v c bnh phi mn tnh. Cao huyt khng iu tr tt cng lm cho ti phnh ln nhanh v v. Tr nhng trng hp c bin chng, nht l v hay da v, khi ti phnh hnh thoi c ng knh ngang < 45 mm ch nn theo di nh k, nu > 45 mm th c ch nh m. Tt c ti phnh dng ti > 30mm u phi m. Chng ti a ra ch nh ny v ng dng t nm 2000 lm gim c t l v phnh phi m cp cu l 10%. Nhiu ci tin k thut m kinh in c ng dng c hiu qu t sau nm 2000 nh ng m bng nh, phu tch ti thiu u trn v u di ti phnh chn mu, a s c ghp v to hnh vi ng thng (72%), 5% phi cm li ng mch mac treo trng di. 1/3 bnh nhn phi m cp cu. Nh ci tin k thut, phu thut tr nn n gin bnh nhn m k hoch nhng m cp cu do v phnh, vn kh l lm sao chn c mu chy cng sm cng tt hi sc, iu tr sc mt mu cng nh ri lon ng mu hiu qu mi mong cu sng c bnh nhn. T nm 2005, chng ti khi s t stent-graft cho mt s bnh nhn c nguy c m m cao v ghp ng mch ch bng-chu qua ni soi bng mt s trng hp chn lc. Kt lun: Vit Nam, 90% phnh ng mch ch bng l do x va thnh mch. Phnh MC do vim chim 1 t l cao Dch t hc, bnh cnh lm sng v cn lm sng c mt s c im ring. T nm 2000, ch nh iu tr thch hp ci thin tin lng: - iu tr ni v theo di nhng ti phnh nh, cha c triu chng. - M k hoch c ch nh vi ng knh ti phnh t 40- 45mm. 95% t kt qu tc thi v lu di tt nhng trng hp m k hoch nhng m cp cu ti phnh v, bin chng v t vong vn cn rt cao. Mt s k thut iu tr phnh MC t xm hi c ng dng trong nhng nm gn y t c nhng kt qu rt khch l.

TIN B IU TR PHNH NG MCH CH BNG TI VIT NAMVn Tn v CS 2

Khoa-B mn Ngoi Lng ngc-Mch mu BV Bnh Dn BV Bnh Dn, 371 in Bin Ph, Qun 3, TP H Ch Minh, Vit Nam E mail: binhdanhospital@hcm.vnn.vn Cc iu tra c bn quc t ngi > 50 tui cho thy phnh ng mch ch (MC) bng thay i t 2 n 9% [3,9,10,11,18] y theo tng vng v lnh th. Vit Nam, mt iu tra c bn nm 2006 ngi trn 50 tui ti 24 qun huyn thnh ph H Ch Minh cho thy t l phnh MC bng l 0.85%, nam l 1.3%, n l 0.3% [14]. Hn 80% phnh MC bng nm di M ng mch (M) thn, hn 30% c kt hp vi phnh hay hp M chu [16] (H.1). Hu ht phnh MC bng c dng hnh thoi (H.2). Phnh dng hnh ti him gp, hu ht l do nhim trng, gy yu 1 vng nh thnh mch, p lc mu lm cho vng ny phnh ln ra (H.3). Khi thnh ti phnh, nt hay v nh, mu chy ra ngoi c cu trc ln cn bao li, x ha v hnh thnh ti phnh gi (H.4). a s ti phnh MC bng, t di M thn tri n ch chia 2 M chu. on ny, phnh hnh thnh do tch vch rt t gp (H.5). Trong mt s trng hp, ti phnh c th v 1-2 lp t trong ra, c xem nh do v, c bit nhm ti phnh vim (H.6). Cng him hn l dng ti phnh gi hnh thnh trong c nng y chu n mn vo t sng tht lng (H.7) 90% cc trng hp ti phnh hnh thoi do x va thnh mch [10,11,17]. Nam b phnh MC bng nhiu hn n vi t s t 5/1 n 9/1 ty sc dn [3,9,18]. Vit Nam t s ny l 4/1 [16]. N b phnh MC bng thng cao tui hn nam v c yu t gia nh. Khi trong gia nh c ngi n b phnh MC bng th cc ngi n cng huyt thng cng th h c nguy c phnh MC bng cao gp 11 ln bnh thng [3,10,21]. Trong iu tra c bn ca chng ti, tui trung bnh nam b phnh MC bng l 60, n l 65 [14].

H. 1: Phnh MC bng di M thn (Van T,/BD hosp)

H. 2: Phnh MC bng hnh thoi (Van T,/BD hosp)

H. 3: Phnh MC bng hnh ti (Van T,/BD hosp)

H. 4: Phnh gi MC (Van T,/BD hosp)

3H. 5: Phnh MC bc tch (Van T,/BD hosp) H. 6: Phnh vim (Van T,/BD hosp)

H. 7: Phnh n mn t sng (Van T,/BD hosp)

H.8: ng m phnh MC bng (Van T,/BD hosp)

Trong 778 bnh nhn m ca chng ti t 1991 n thng 6, 2010: 6 gia nh c t 2 n 3 ch em b phnh MC bng m hu ht l n. Nm 1952, Dubost Php [6] l ngi u tin ct-ghp thnh cng mt ti phnh MC bng vi ng ghep ng loi. M, 2 nm sau, Cooley [2], m cu sng mt ngi b v ti phnh MC bng. T , nh k thut tin b, t vong do m phnh MC bng di M thn gim dn cn di 20% [5,7,8,9,11]. nc ta, GS Nguyn Hu ct-ghp thnh cng phnh MC bng di M thn t nm 1968 [13]. V ti phnh thng dn n t vong do sc mt mu, v vy cn can thip phu thut trc khi v. Nhiu nghin cu cho thy t l v ti phnh MC bng ph thuc vo ng knh ca n, ti phnh cng ln, nguy c v cng cao [2,5,20]. Trong 2 nghin cu ca chng ti nm 1999 v nm 2005, theo di 18 thng, t l v ti phnh MC bng di M thn c ng knh >50mm l 30% [13]. Ngoi ra, c 2 yu t thun li gy v l huyt p (HA) cao (HA tm trng >100mmHg) v vim phi mn tnh (COPD). Theo nh ngha quc t, gi l phnh M khi ng knh ca n ln hn 1.5 ln ng knh ca M bnh thng ngay trn ch phnh. Theo nh lut Starling, khi ng knh ti phnh cng ln th tc ng ca p lc mu ln thnh ti phnh cng cao. Kh nng chu ng ca thnh ti phnh gim hn khi kch thc ti phnh ln hn 2.5 ln ng knh M bnh thng. Lc ny, cn phu thut ctghp trnh v phnh t nhin [2,4,5,8,20]. ngi Vit Nam, theo cc s liu iu tra c bn ca chng ti, siu m o ng knh ngang MC bng ngi bnh thng l 16mm n v 17mm nam [15]. V th, gi l phnh MC bng khi ng knh ngang ch dn 24mm n v 26mm nam, ch nh phu thut trnh v phnh t nhin ng knh ngang 40mm n v 45mm nam [16]. Sinh bnh l [2,3,9,18,20] 4

Theo Cooley, s hnh thnh v pht trin phnh MC bng di M thn ty thuc vo 3 nhm yu t: (1) cu trc ca thnh MC; (2) huyt ng hc; (3) cc yu t vt l. Thnh MC di M thn c nhiu collagen. Cu trc ny thun li cho vic ng cholesterol v calcium, gy ra x va thnh mch. on ny, dng mu chy xoy do c nhiu M nhnh ln nh M thn tng, M mc treo trng trn v 2 M thn. Phn cui MC bng li chia lm 2 nhnh chnh, khi n ch chia, mt phn dng mu chy b di li vo thnh MC bng (vn b x va), to thnh tng t sng theo nhip bp ca tim, v tc ng lin tc ln thnh mch. Cc yu t ny phi hp nhau lm cho on MC bng dn dn ra v hnh thnh ti phnh. Tht ra, cc yu t tht s gy hnh thnh v pht trin phnh MC bng on ny rt phc tp. y l mt qu trnh tng tc sinh hc, l hc v ha hc phc tp, bao gm nhiu bin i sinh ha ca t bo, huyt ng, ly gii protein [2,4,5]. Phnh MC bng di M thn c v tng hng nm, mt phn do cc phng tin chn on hnh nh ngy cng hin i, phn khc do tui th. Chn on [5,7,8,9,11,13,19,21] - Lm sng: Chn on c bn da trn lm sng. Mt khi u bng s c, c khi thy c, quanh rn p, chiu ngang co dn theo nhp tim. ngi mp, kh s v xc nh kch thc khi u. Trong mi trng hp, cn phn bit vi cc tnh hung: on MC bng di v un khc. MC bng bnh thng ngi m v ct sng lng n ra trc. Khi u trong phc mc hay sau phc mc vo MC bng. ngi khng mp, s nn k c th c lng c kch thc ti phnh v quan trng hn xc nh gii hn trn ca ti phnh nm trn hay di M thn (du hiu De Bakey (+) khi b trn ti phnh nm di h sn). Khi v, gii hn ti phnh khng cn r, bng cng au (t mu sau phc mc), chng (lit rut), mch v huyt p thay i (tin sc hay sc do xut huyt ni). Khai thc k bnh s, ch cc chi tit: Bit c phnh MC t trc. Tng c 1 u bng, p theo nhp tim, khng au. Cc triu chng x va thnh mch: cao HA ( hoc cha iu tr), tai bin mch mu no, suy thn mn, bnh mch vnh, thiu mu chi di... Cn bt mch bn, khoeo, c chn, bn chn v xem da cc ni c thay i khng (lnh, ti, tm) T nm 1991 n ht thng 6 nm 2009, chng ti khm v iu tr cho 1335 bnh nhn phnh MC bng: - Bnh cnh lm sng nh sau: (Bng 1) V tr, kch thc, tnh cht u bng (n=1335) U bng, khng au U bng, au ng knh ngang < 40mm ng knh ngang > 40 50mm ng knh ngang > 50mm U bn tri rn U bn phi rn U quanh rn Tin s bnh tim-mch (n=1335) Cao HA Tai bin mch mu no Thiu nng vnh (ECG, siu m tim) Thiu mu chi di % 65 35 40 30 30 55 25 20 % 50 3 21 24 5

Bt c mch chi di (n=1335) Chn phi: - Mch i - Mch khoeo - Mch bn chn Chn tri: - Mch i - Mch nhng - Mch bn chn Da 2 chi Chn phi: Lnh v ti tm t u gi : Bn chn b hoi t cc ngn Chn tri : Lnh v ti tm t u gi : Bn chn b hoi t - Cn lm sng: Xt nghim mu (Bng 2): XN mu (n=1335) Cholesterol > 4.9mmol/L Triglycerid > 1.7mmol/L - HDL > 0.8mmol/L - LDL < 4mmol/L Glycemia >1.4g/L US > 8.3mmol/L Creatinin > 97 mmol/L EF > 60% Child-Pugh A VDRL (+) :

% 80 74 72 71 69 67 8% : 5% : 12% : 6%

% 52.00 55.17 10.34 58.62 9.00 12.00 21.00 78.00 93.00 0.20

- Hnh nh: Nhng phng tin chn on hnh nh nh siu m Doppler mu, CT scan, CT-A, MSCT, DSA, MRI c ng dng ty tng i tng v phng tin hin c, cho php kho st hnh nh ng v tnh MC bng v ti phnh: v tr, kch thc, lng ti phnh, thnh ti phnh, u trn, u di ti phnh, cc M nhnh, M thn tng, M mng treo trng trn, 2 M thn, M mc treo trng di v 2 M chu. Tuy nhin, mt c s y t khng chuyn su, khm lm sng k, siu m bng, chp x quang bng khng sa son c th pht hin bnh phnh MC bng 80-90% trng hp. MSCT-64 lt ct v dng phn mm to dng hnh nh 3 chiu cho php kho st y cc chi tit gip ch nh iu tr, lp k hoch phu thut, k c t stent-graft [13,16] (Bng 3). Kt qu chn on hnh nh (n=1200) Hp M cnh > 75% Hp M thn > 50% Do v hay v ti phnh Phnh M chu Hp M chu-i Mu cc bm thnh dy v hp lng ti phnh SA tim: Cho bit chc nng tim: : Suy van : 52% 6 % 12 7 36 22 27 41

: Tim ln : 56% : EF > 60% : 90% Cc tnh hung lm sng, din tin v bin chng ca ti phnh c ch nh iu tr thch hp, bc s iu tr cn bit cc tnh hung lm sng, c im ca ti phnh v cc tn thng kt hp nhng M khc (Bng 4). Cc tnh hung ca ti phnh (n=778) Cha v v ang v Tch vch Hp hay tc lng Vim Nhim trng Ti pht R: - vo TMC - vo ng tiu ho c tnh v v tr ti phnh (n=1000) Phnh hnh thoi (lu i xng hay khng) Phnh hnh ti Phnh di M thn Phnh ngang M thn Kt hp tn thng M khc (n=1000) Phnh on hay M khc - MC trn M thn (ngc, ngc-bng) - M chu: - phi - tri - phi v tri - Phnh MC nhiu ni Hp hay tc MC - MC trn M thn (ngc, ngc-bng) - M chu-i: - phi - tri - phi v tri - Khoeo- cng-bn chn: - phi - tri - phi v tri - Phnh-hp an xen Bnh khc kt hp Suy tnh mch Ung th tng Tiu ng Bnh phi tc nghn mn tnh (COPD) Bnh h thng Suy thn mn Bnh lnh tnh cc tng Ch nh iu tr: 7 % 67 11 22 1 2 14 7 4 0.01 1 % 94 6 76 24 % 16 17 21 14 6 7 11 12 16 13 14 17 13 % 28 3 8 10 6 11 17

Ch nh iu tr da vo ng knh ngang ti phnh, hnh dng ti phnh, bin chng ca chnh ti phnh hay do ti phnh gy ra, bnh mch mu kt hp lin quan n ti phnh: Trong nghin cu ny, cc ch nh phu thut gm: - Phnh MC di M thn, hnh thoi, c ng knh ngang 45mm nam v 40mm n. - Phnh MC di M di M thn, hnh ti, c ng knh ngang 30mm. - Phnh MC di M thn, kch thc nh nhng c phnh M chu 30mm. - Phnh MC di M thn, kch thc nh nhng c u trn, u di hay M chu hp nng. - Phnh MC di M thn c bin chng: Da v, v, phnh gi, r vo tnh mch hay vo ng tiu ho. Lng ti phnh hp nng - tc do x va hay mu cc. Thuyn tc M h lu do mnh va hay cc mu ng. Chn p niu qun, tnh mch do vim x lan rng. Ch nh theo di v iu tr ni cho cc trng hp: - Phnh MC di M thn, hnh thoi, c ng knh < 40 mm n hay < 45 mm nam. - ng knh ngang ti phnh ln, cha c bin chng, nhng khng phu thut do: Bnh nhn t chi m. C bnh mn tnh kt hp m tin lng sng khng qu 1 nm. Trn 80 tui, c nguy c phu thut cao (ASA 3 4). Da vo cc ch nh trn, phn phi cc nhm iu tr 1335 bnh nhn nh sau (Bng 5): Ch nh iu tr (n= 1335) Ngoi khoa Ni khoa - theo di S bnh 778 (58%) 593 (42%) % 76 3 5 10 2 4 % 82 3 6 9

Phn phi bnh m (n=778) Phnh hnh thoi ln 45 mm nam, 40mm n Phnh hnh ti 30 mm Phnh MC nh + Phnh M chu 30 mm Phnh c bin chng (v, do v, hp, tc lng, r) Thuyn tc M h lu Phnh MC nh + tc-hp M chu-i Phn phi bnh cha m (n=593) Phnh hnh thoi, < 45mm nam, < 40mm n Phnh ln nhng bnh nhn t chi m Phnh ln + bnh mn tnh nng Phnh ln, BN > 80 tui, ASA III - IV

Nguyn tc iu tr ngoi khoa [2,13] - Chun b trc m: Pht hin v iu tr tt bnh nn: bnh mch vnh, phi, thn. Chun b trc m k hoch tng t nh chun b m cc bnh trong bng. B dch in gii ngy trc m. Chun b mu, plasma ng lnh, cc yu ng mu cn thit, cc thuc tim-mch, thuc vn mch, my thu hi mu v hon truyn. Nu c phng tin, c th ly mu ngi bnh trc m hon truyn lc m. - Gy m: Khm tin m cn thn: huyt p, ch s khi c th (BMI), bnh mch vnh, bnh van tim, c tim, bnh thn, bnh phi, bnh gan, tiu ng, tng trng, tin cn phu thut c gy m, c bit l phu thut tim-mch c dng thuc chng ng, chc nng ng mu Gy m NKQ, dng thuc dn c tt, c my theo di du hiu sinh tn vi HA xm ln, catheter vo tnh mch trung tm hay ng Swan-Ganz (nu c) theo di HA v p sut trong nh phi. Cn 2 ng truyn tnh mch b dch v mu khi cn. 8

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Sau khi gy m, vng bng v bn c co sch lng v st khun. t ng thng Foley theo di lng nc tiu trong lc m v sau m. ng m: ng trng gia bng cn rng kp ngang on MC trn ti phnh, 2 M chu v khu ni ng ghp vo MC- chu (H.8). Nguyn tc phu thut: Phu tch on MC trn ti phnh v 2 M chu chung va kp ngang (H.9). Trnh x phc mc trc M chu tri bo tn m ri thn kinh c chc nng cng dng. Duy tr huyt p bnh thng. Cho heparin tnh mch trc khi kp M (H.10) X dc ti phnh, trnh ct ngang M mac treo trng di c th cm li cho d khi cn (H.11)

H. 9: Kp M trn v di ti phnh (Van T,/BD hosp)

H. 10: H huyt p trc khi kp MC (Van T,/BD hosp)

H. 11: X dc ti phnh. (Van T,/BD hosp)

H. 12: Dng gc bao che rut (Van T,/BD hosp)

9H. 13: ng m sau phc mc, Phnh > thn (Van T,/BD hosp) H.14: Phu tch v gi cc M tng: Phnh > thn (Van T,/BD hosp)

Vi 778 bnh nhn m, chun b trc m v gy m v hi sc nh sau (Bng 6): Chun b trc m v gy m iu tr cao HA bng Nicarpidine iu tr h HA bng Epiphedrine Duy tr mch (60-80 nhp/pht) Gy m Tin m/midazolam/fentanyl Thiopental (hoc propofol), fentanyl, Atracurium (hoc vecuronium) t ni kh qun / gip th Duy tr: fentanyl/isoflurane (hoc propofol) Truyn Lactate Ringer (hoc saline 0.9%)/CVP Truyn mu Truyn huyt tng ti lnh Theo di huyt p xm ln - heparine - kp MC - nh kp - protamine Nc tiu/hr = 30-60ml Hi sc Gip th/an thn > 12gi Rt ni kh qun/ HA n < 12gi iu tr HA cao/Nicarpidine (tm trng >16cmHg) Theo di HA, mch, SaO2, SaCO2/24 gi Nhi mu c tim cp/Troponin I (+) Th oxy lin tc/ 4 lt: SaO2>95% Gim au/efferalgan/Nfopam Buvicaine/ Epidural catheter % 57 12 89 % 100 100 100 100 80 100 40 32 100 78 % 14 83 21 100 2 100 100 0

Phu thut phnh MC bng di M thn, cha bin chng: - ng m cn bn: M bng dc gia trn v di rn. Vo bng, thm st ti phnh, cc tng ri ko ht rut non ra ngoi, bao che bng gc t (H.12). Xem xt k MC trn ti phnh, cc tnh mch v M thn tri, cc M chu v M mc treo trng di. Quay bn m qua phi 30 o. Nu bnh nhn mp, c th vo bng qua ng m ngang. - ng m vo sau phc mc: Nm nga, nghing phi 30-45o. X da hnh ch S t u sn 12 hay dc di sn 11, i xung vo gia n xng mu (H.13). Gn c v c c x v tch ra 2 bn l phc mc sau. Tch phc mc vo su n xng sng bc l c ti phnh u trn, ln xung di bc l 2 M chu (H.14). Kp ngang trn v di tii phnh, x v ly ht mng x va trong lng, khu cc l M lng ang chy v ghp ni nh thng l. ng m ny c nhng u im: Khng cn tch rut dnh nhng trng hp c tin cn phu thut bng. Thi gian lit rut sau m ngn. 10

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Khi c ti phnh ngn, nm cao ngang hay trn M thn, phu tch v cm li M thn tri khng tr ngi. Nhng nhc im ca ng m sau phc mc: Kh phu tch v khu ni M chu phi Khng bit c tn thng cc tng trong bng nht l thiu mu nui i trng xung v sigma. Phu trng khng c rng. C th b s bng hng gy mt cn i vng bng. Phu tch MC: Sau khi vn i trng ngang ln cao l gc Treitz. X phc mc khong 3cm bn ngoi gc Treitz, dng tay tch nh vo sau c ti phnh t kp ngang MC (H.9). Nn kp st M thn tri, lu cc tnh mch tinh hay bung trng. u di, x dc phc mc, t ch chia ch-chu xung di khong 4cm, v tch ra 2 bn bc l 2 M chu chung. Nu c phnh M chu, cn phu tch su hn bc l M chu ngoi v M chu trong. Cn thn, trnh gy tn thng tnh mch chu v niu qun cng nh m ri thn kinh h v trc M chu chung tri. Chn ng ghp: Hu ht ng ghp nhn to chng ti ang dng do hng B.Braun cung cp. Trc nm 1998, hu ht ng ghp nhn to do hi ADVASE, BS. Trn Vit T v mt s gio s M tng. Chng ti dng ng ghp thng cho 72% trng hp, cn li l ng ghp Y. Kch thc thng dng l 18mm cho nam v 16mm cho n. Khi khng c ng ghp Y, chng ti dng ng ghp thng ni tn-tn vi 1 M chu v tn-bn vi M chu cn li. Tt c nhng trng hp ny, ng ghp u hot ng tt, cha b bin chng hp hay tc. mi trng hp nh vy, chng ti tit kim c 100 USD (H.15). Nu bit ci tin, mt ng ghp Y c th dng ghp 2 trng hp: 1 trng hp ghp Y v 1 trng hp ghp thng c to hnh. Nh vy, ph tn ng ghp ch cn li 50%. Kp MC v chun b ghp: Trc khi kp MC, cn h huyt p tm thu xung cn 1012cmHg v chch hparin (0.5-1mg/kg) tnh mch. Trong trng hp cc M chu b vi ho cng, thay v kp ngang, chng ti dng ng thng foley bm bng chn mu t bn trong (H.16). Nn x dc ti phnh lch phi, trnh ct ngang M mac treo trng di cm li cho d khi cn (H.11). Ly ht mu cc v cc mng x va trong lng ti phnh, st trng bng betadin m c (H.17). Khu cm mu cc l M lng ang chy (H.18), dng kp mch mu kp tm M mc treo trng di. Ghp: on trn ti phnh, x ngang na chu vi mt trc, ct lc n m lnh mi ni vi ng ghp chc v khng hp (H.19). Chng ti thng khu mi lin tc, ly cc lp ca thnh mch, bt u t mt sau, ngay trong lng MC vi ch prolene 3-0 hay 2-0 (H.20). Sau khi b th kp, nu cn r mu th khu b sung (H.21). Tng t u trn, chun b u di ngay trn ch chia 2 M chu (nu ghp ng thng) hay 2 M chu (nu ghp ng Y). Trc khi khu ni nn nh kp M chu (hay x bng foley) lng gi mu hi lu.

11H. 15: Ghp-to hnh (Van T,/BD hosp) H.16: Dng Foley chn mu (Van T,/BD hosp)

H. 17: Mu cc trong lng ti phnh (Van T,/BD hosp)

H. 18: Khu cc l M lng (Van T,/BD hosp)

H. 19: Chun b ghp-ni u trn (Van T,/BD hosp)

H. 20: Khu mi lin tc (Van T,/BD hosp)

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Nu khng c mu hi lu, nhiu kh nng do cc mu ng M chu-i, dng Fogarty ly ht mu cc. Ghp-ni bng ch prolene 3-0 hay 4-0. M kp: M kp M chu trc. Gy m truyn dch nhanh (H.22), nng huyt p ln bnh thng ri m kp MC t t gi HA lun gn bnh thng (H.23). Nu c ri lon ng mu th cho protamin v plasma ti ng lnh. a s trng hp ng ghp thng, mu lu thng tt xung 2 chn. Rt t trng hp, sau khi m kp, mu khng qua ng ghp hay qua ng ghp nhng khng n M chu. L do c th gp l ming ni b hp hay tc, mu ng trong ng ghp. Cn ni ghp li hay m ng ghp ly sch mu cc v dng thuc chng ng. Trong nhm bnh nghin cu ca chng ti, nhng tnh hung ri lon ng mu hay mu cc lm tc ng ghp ch gp nhm m phnh v. Khu ni li M mc treo trng di: Sau khi khu ni xong u trn, nn xem xt tinh trang cp mau cho i trng xung va sigma. Nu nghi ng thiu mu nui th phi khu ni li M mac treo trng di vo ng ghp (H. 24), nht la khi phi khu-buc M chu trong tri (nhnh tri ng ghep hinh ch Y c ni ghep tn-tn vi M chu ngoi - H. 25) v M chu trong phi b tc. Nn lu l khi hoi t i trng sigma thng km theo lit h chi. Co 5% trng hp ct-ghp MC bng di M thn, chng ti phi cm li M mac treo trng di (Bng 7). Phu tch MC v cc M chu: Chng ti ch trng phu tch cng t cng tt, ch va kep ngang tam thi (Bng 7). 12

Chi tit phu thut (n=742) ng m: - Nm nga, ng m trng gia - Nm nga, nghing phi 30o, ng m sau phuc mac Loai ng ghep (Dacron B. Braun, 16mm n, 18mm nam): - Thng - Y Thi gian kp MC: - 30-45 pht - 45-60 pht - > 60 pht Kp tam M chu Khng kp M chu, dung Foley cm mau tam Ky thut ghp, khu ni trong long MC Sau bo kp MC: - Co dung protamine - Khng dung protamine Khu ni li M mac treo trng di % 98 2 72 28 65 20 15 62 38 100 85 15 5

H. 21: Kim tra ch khu ni (Van T,/BD hosp)

H. 22: Truyn dch nng HA/ khi b kp (Van T,/BD hosp)

H. 23: B kp ton b (Van T,/BD hosp)

H. 24: Cm li M mc treo trng di (Van T,/BD hosp)

13H. 25: Ni tn-tn ng ghp-M chu ngoi (Van T,/BD hosp) H. 26: Kp MC ngc (Van T,/BD hosp)

Nhng trng hp c bit - Phnh MC di M thn v: Cn phn bit 3 nhm Nhm v t do vao bng: bnh nhn nhp vin trong bnh canh sc mt mau, bng cng au va khng, ti phnh khng s c. Ch nh m cp cu cn nhiu bn ci do ty l t vong rt cao [2,4,5,8,9]. Trong nghin cu ca chng ti, co 5% trng hp phai phu thut cp cu do v ti phinh gy sc mt mau [13]. Bnh nhn c hi sc tch cc ng thi can thip phu thut ti khn. Ngay khi m bung, kim soat u trn ti phinh cm mau tam (dung tay hay dung cu ep MC vao ct sng), hi sc tch cc cho n khi HA tm thu 80mmHg th tip tc phu tch u trn ti phnh va ct-ghep. Nu c phng tin, bac si gy m lun 1 catheter c bng ln qua M cnh vo MC ngc xung n on MC di c honh, bm cng bng ri ko ngc ln ap sat bong vao l c honh cm mau tam. Khi m bng, v tm v kp ngang oan MC trn ti phinh rt kh nn c th dng Foley 28F lun qua ch v (hay qua l x mt trc ti phnh) ln trn c honh, bm bng v ko xung ap cht bong vao l c hoanh cm mau tam. Co khi phai kep ngang MC ngc xung (m ngc trai) hay ngay di c hoanh. Khi a hi sc co hiu qua va kim soat c tinh hinh, chuyn kep xung oan di M thn trc khi tin hanh phu tich va ct ghep. Sau khi kp c oan MC ngay trn ti phinh, bac si gy m tip tc truyn mu, bac si phu thut xem xet cc tn thng tnh mch co th gp lc phu tch m u trn. Phu thut ct-ghep s thc hin nh khi m ti phnh bnh thng. V lun c ri lon ng mu nn phi truyn nhiu plasma ti hay ng lnh, tiu cu v fibrine, nht l lc b kp sau khi khu ni. Nguyn nhn chnh gy t vong l ri lon ng mu. Ngoi ra, cn do sc mt mu khng hi phc, nhim trng h hp, suy thn, suy a tng. Sau m, ch 50% trng hp c cu sng nu c hi sc tch cc. Tin lng s tt sau m nu huyt ng hc n (nh kp thi truyn mu, cc yu t ng mu, dung dch in gii) v dng thuc vn mch ngn hn; t th sau m 24-48 gi; lng nc tiu nhiu (d creatinin mu c tng); tri gic tt; khng st cao. Nu suy thn v huyt p thp, cn phi dng my lc thn lin tc hay siu lc. Nhm v sau phc mc: t ngt au bng, ti phnh ln nhanh, mch nhanh dn. Siu m gip chn on xc nh. Cn m cp cu, phi chun y b mu v cc yu t ng mu. Cc bc tin hnh phu thut tng t nh v t do vo bng. Nhm phnh gi (H.27): c xem l ti phnh v khu tr. Tuy him gp nhng thng do nhim trng thnh mch. iu tr phc tp, tin lng km do tn thng thng nhiu ni trn h M, nht l M tng (H.28). Ti phnh au, bnh nhn st nh, bch cu trong mu tng. Cn chun b bnh nhn chu o m bn khn. Tt nht l ct b ton b on MC tn thng, thay th bng ng ghp, dng khng sinh ph rng. Sau m, theo di st, nh k pht hin v iu tr phnh ti pht, nht l khi cha xc nh v loi b c ngun nhim. Trong nhm bnh nghin cu, chng ti ghi nhn c 3% phnh gi, bin chng v t vong sau m gp i nhm phnh do x va. - Phnh MC di M thn do v: thng xy ra nhng ti phnh ln, biu hin au lin tc, m ti phnh hay lng, kch thc ti phnh ln nhanh. Chn on hnh nh thy tch vch, thnh ti phnh mt i xng (c ch dn rng bt thng), nhiu mu cc bm vo thnh trong 1 14

lm hp dng chy (H.29). Cn chun b chu o m bn khn. Khi m bng, c th thy mu tm nhun mt t ra ngoi. X ti phnh, ly ht mu cc v mng va, c th mt ch v lp trong v lp gia. Chng ti gp 23% trng hp nh vy trong nhm bnh nghin cu. Nh tm sot v qun l cht ch, s bnh nhn phnh MC bng v phi m cp cu gim dn, t 60% nhng nm trc 1995, hin cn khong 30%. - Phnh MC di M thn vim: L nhng ti phnh MC bng nh, au. CT scan thy thnh ti phnh dy, lng hp, thng c tch vch lp trong. Phn ng vim x vng sau phc mc quanh MC c th gy chn p niu qun, cc tnh mch, i khi c t-hng trng. Tc lng mu (VS) tng. Phu thut kh do kh phu tch (m vim x), kh khu ni (m vim dy), nht l khi c tch lp trong, lp ngoi vim dy nn ng khu ni kh chc. Sau phu thut nn theo di st. Tuyt i b ht thuc l. C th dng thm thuc chng vim. Nhm phnh ny, chng ti gp khong 15% trong cc bnh nhn m. - Phnh MC di M thn nhim trng hay phnh hnh ti (H.30): Tn thng thnh mch do nhim trng (sau nhim trng huyt nh thng hn hay vim ni tm mc), ph hu 1 phn thnh mch t bn trong; di tc ng ca huyt p, ch thnh mch yu bung dn thnh hnh ti. Tc nhn gy bnh c th l cu trng hay trc trng, c khi do lao hay giang mai... Khm lm sng, thng pht hin au ti phnh, Kch thc ti phnh ln dn n lc v, thng l > 30mm. Nu qu trnh nt-v xy ra chm th m vim hnh thnh bao quanh lm thnh mt ti phnh gi. Nu iu tr khng hiu qu nhim, vi trng vo mu, tri i c th hnh thnh nhiu ti phnh cc M khc v phu thut thng khng cn hiu qu. Khi loi b c ngun nhim, phu thut thay c on MC b tn thng l cn thit. Loi b hon ton ngun nhim (thng l vim ni tm mc) c vai tr quyt nh kt qu iu tr, trnh c ti pht. Trong nghin cu ca chng ti, nhm ny chim 5% cc trng hp c phu thut. - Km ung th hay bnh mn tnh cc tng (H.31): Ngoi phnh MC di M thn, bnh nhn c th km cc bnh mn tnh hay cp tnh khc. Do phnh MC l bnh ca ngi nhiu tui nn lun phi truy tm cc bnh kt hp khc, nht l ung th tng. Tr trng hp c bin chng phi m cp cu, nhng trng hp m k hoch cn cn nhc nn m bnh no trc hay can thip cng lc. V nguyn tc, khi can thip cng lc th nn ct-ghp MC trc, sau khi ng kn phc mc sau mi x l tn thng cn li. Nu tin lng ngi bnh khng sng hn 1 nm (do bnh kt hp) th khng nn m ct-ghp MC, tr khi ti phnh c bin chng. Trong nghin cu ca chng ti, nhm ny chim 10% cc bnh nhn m nhng ch c 1/3 trng hp l c ch nh m c 2 bnh. - Phnh MC di M thn trn c a bnh mch vnh, bnh mch cnh, mch thn c triu chng (hp lng >75%). Do x va thnh mch l bnh M h thng nn trc khi quyt nh m ghp MC bng cn xem xt cc tn thng M khc kt hp c chin lc iu tr. C khi phi u tin iu tr trc tn thng M khc, nht l tn thng M vnh, M cnh, M thn. Nu c phng tin v k thut th c th can thip cng lc tn thng MC v cc M khc. Ni chung, ty tng tnh hung c th, ty vo c im tn thng MC v cc M khc c k hoch iu tr thch hp vi mc tiu gii hn bin chng v t vong mc chp nhn c. Trong nghin cu ca chng ti, nhm ny chim 9% cc bnh nhn m v tt c u c can thip 2 th. T nm 2005, hi ADVASE, bc s Cardon, bc s DeSoutter [12,16] gip chng ti thc hin t stent-graft cho mt s trng hp phnh MC bng di M thn c nguy c phu thut cao, kt qu hin ang tt (H.32). (Bng 8)

1 15

H. 27: Lng phnh gi MC (Van T,/BD hosp)

H. 29: Thnh ti phnh mt i xng - do v (Van T,/BD hosp)

H. 30: Phnh hnh ti (Van T,/BD hosp)

H. 31: Phnh v ung th T sigma (Van T,/BD hosp) H. 32: Stent-graft (Van T,/BD hosp)

1 16

Cc ti phnh MC c bit Phnh v: - t do vo xoang phc mc - sau phc mc - khu tr (phnh gi) Phnh do v Phnh vim Phnh nhim Phnh + ung th hay bnh mn tnh cc tng Phnh + tn thng M khc

% 5 11 3 23 15 5 10 9

Bin chng, m li v t vong chu phu do bnh l ti phnh (n = 778) (Bng 9) Bin chng phu thut chung l 30.9%, trong 3.5% phi m li do chy mu, thiu mu cp chn, hoi t rut, tc ng ghep, bung thnh bng. T vong chung l 7.9% (m k hoch l 2.5%, m cp cu l 35%), do sc mt mu, nhi mu c tim, suy h hp, suy thn v suy a tng. Bin chng, m li v t vong Bin chng M li T vong chu phu: - m k hoch - m cp cu Bin chng chu phu (30 ngy) Sc mt mu (v phnh) V on MC trn ti phnh (do kp) Chy mu - ri lon ng mu Nhi mu c tim cp Suy thn Suy h hp - th my Suy tim Thiu mu chn cp tnh Thiu mu nui i trng sigma Thiu mu nui ty Bung thnh bng Nhim trng vt m Tc ng ghep (mu cc) Suy a tng Nhim trng huyt Tng S ca 22 4 8 9 53 39 11 8 4 2 2 12 4 13 1 218 (28%) m li 0 0 7 0 0 0 0 12 4 0 2 3 4 0 0 25 (3.2%) % 28 3.2 7.2 2.5 35.0 T vong 10 1 4 7 7 8 2 2 0 0 0 0 1 13 1 56 (7.2%)

Suy a tng: thng l bin chng sau cng ca h HA ko di do sc mt mu khng hi phc. Cc yu t nguy c phi hp khc: C bnh nn mn tnh nh suy tim, suy thn, suy h hp. Ri lon ng mu sau m. Hu ht bnh nhn suy a tng u t vong. V th cn phng nga h HA ko di v iu tr sc mt mu tht tt trnh nguy c suy a tng. Suy thn: thng gp suy thn nh v thong qua sau m, biu hin: creatinin mu > 100mg/dL, K+ mu khng tng, lng nc tiu vn nhiu. Trong nghin cu ca chng ti, sau m c 8.6% trng hp suy thn, nguyn nhn: C suy thn mn t trc, nng thm sau m: 1.8%. 17

HA h ko di (sc mt mu): gy suy thn cp, mt s phi lc mu. Ngoi ra, cn do b kp MC (sau ghp) khi cha b dch. Thuyn tc M thn do mu cc hay mnh va: gy suy thn nng, thng do phu tch v kp on MC c nhiu mng x va, mu cc, ngay st M thn. Khi chn on c suy thn do thuyn tc M thn, nn m li sm thng M thn. Suy h hp: Xy ra bnh nhn c suy h hp trc m (trong nhm bnh nghin cu ca chng ti c 1.6% b COPD) v phi m cp cu cha chun b tt h hp. Cc yu t nguy c suy h hp c ghi nhn: truyn nhiu mu v dch; gip th ko di > 48 gi [21]. Trong nhm bnh nghin cu ca chng ti, c 6.4% suy h hp sau m, cn th my ko di, thm ch khng cai my gip th c. Tnh chung, c 1.3% trng hp t vong do suy h hp. Mun gim bin chng ny, tr trng hp m cp cu, cn iu tr h hp v tp vt l tr liu h hp, tp ho khc trc m cho n khi chc nng h hp ci thin, t mc an ton. Bin chng tiu ha: Ngoi lit rut ko di, thiu mu i trng sigma l mt bin chng nng, c th gp t 1-6% sau m ct-ghp phnh MC bng di M thn [2,4,5,8,9,21]. Sau m 1 ngy, ngi bnh c th i cu phn c mu en, hi, bng chng hi, bch cu tng, c khi c du hiu vim phc mc. Soi i trng sigma thy nim mc rut nht nht thiu mu. Nu ch thiu mu nui lp nim mc i trng, bnh c th t khi do c th t iu chnh t ngun cp mu khc. Khi thiu mu nui c lp c, i trng s hoi t hay teo hp dn. V vy, khi thiu mu nui lp c, cn phi m li, ct b on i trng hoi t hay lm mn hu mn nhn to ty tn thng c th. Khi m li, lun phi che chn cn thn trnh nhim trng ng ghp. Trong nhm bnh nghin cu ca chng ti, tnh hung ny chim 0.65%, tt c u phi m li. Thiu mu ty sng [21]: rt t khi b lit sau m ct-ghp phnh MC bng di M thn, tr trng hp vng chu b thiu mu hon ton do buc c 2 M chu trong v M mac treo trng di. Ngoi lit, bnh nhn thng c biu hin thiu mu nui i trng sigma v hoi t da vng mng. Nh vy, khi ct-ghp phnh MC bng di M thn, cn bo m c t nht 1 ng mch chu trong cp mu tt hoc tt nht l khu ni li M mac treo trng di. Trong nhm bnh nghin cu ca chng ti, c 2 trng hp lit sau m v mt cm gic vng mng. Cc yu t nguy c trong phu thut (Bng 1, 4, 8, 9) Ti phnh v: l yu t nguy c hng u, nht l khi v t do vo bng hay v sau phc mc. Ri lon ng mu nng: l nguyn nhn t vong hng u trong nhm bnh nghin cu ca chng ti, thng do v ti phnh v khng b mu, cc yu t ng mu kp thi (trc, trong v sau m). Sau m, nu c biu hin xut huyt ni v cha ri lon ng mu nng, nn m li ngay khi chun b mu v cc yu t ng mu. Khng t trng hp s tm thy mt vi ch chy, khi khu cm mu c, nhiu hy vng bnh nhn thot khi cn nguy kch. Kh nht l khi chy mu nhiu trong bng, ri lon ng mu nng, huyt p thp, kinh nghim cho thy, nu c mu v yu t ng mu th cng nn mnh dn m bng li thm st, may ra tm c mt vi ch chy mu c th khu cm mu c. Nu ch hi sc ni khoa, bnh nhn kh trnh t vong. C bnh nn mn (tiu ng, bo ph, suy thn, suy h hp, suy tim): cc bnh mn tnh c t trc lun nng thm sau m nn cn iu tr tht tt trc m. C khi phi cn nhc li ch nh v phng php phu thut, phng php v cm cho tng trng hp c th. Sau m, nu cc bnh nn ny nng thm th nguy c t vong rt cao. Thiu nng tun hon chi di v tn thng nhiu M: l nhng yu t nguy c c xc nh. Trc m, a s bnh nhn c thiu nng tun hon chn. Sau m, tnh trng ny thng nng thm. Ngoi ra, tn thng x va gy hp thng c nhiu M khc nh M cnh, M vnh, M thn, M mc treo Trong nghin cu ca chng ti, ngoi phnh MC bng, 50% bnh nhn c tn thng gy hp cc M khc. Nhi mu c tim cp, thiu mu chn gp phn khng nh vo t l t vong sau m. Nh vy, tr trng hp cp

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cu, khi chn on c c tn thng M khc, nn cn nhc can thip u tin hay cng lc vi phnh MC bng. Din tin v bin chng xa: Theo di lu di, ngoi cc bnh mn tnh, ung th, tui gi v suy mn, bin chng do ng ghep v k thut chim 11%, trong 6.7% phi m li v 1.5% t vong. Bin chng ng ghep gm t mu quanh ng ghep, tc ng ghep, nhim trng ng ghep, r ch ni gy phnh gi hay r vo vo hng trng. Rt kinh nghim t nhm bnh nghin cu, chng ti thy c th gim cc bin chng ny bng cch dng ng ghep tt; chn on MC cn tt khu ni; cn ly cc lp ca thnh mch; khu cm mu k cc M lng; ct xn thnh ti phnh v khu bao quanh ng ghep, khu phc mc sau che kn ng ghep, nht l u trn, trnh ng ghep tip xc trc tip vi hng trng (c th chn mc ni ln). Bin chng mun do ng ghep hay do k thut (n = 778) (Bng 10) Bin chng Thiu mu chi di Thot v thnh bng Tc ng ghep T mu quanh ng ghep Nhim trng ng ghep R ng khu gy phnh gi R MC- hng trng Tng S ca 23 6 6 19 11 4 4 73 (9%) M li 18 (4 ct chi) 6 5 1 10 2 2 44 (6%) T vong 1 0 1 1 3 2 2 10 (1.3%)

iu tr v kt qu nhng bnh nhn ch theo di (n = 593) (Bng 11) Ngoi theo di v iu tr cc bnh mn tnh, tt c nhng trng hp khng m c chng ti iu tr v theo di nh k c ch nh iu tr ng lc. - Thuc iu tr ngoi tr: Aspirine (81mg/ngy) + Doxycycline (100mg/ngy). Ngoi ra, cn c thuc iu tr bnh nn (HA, COPD, bnh mch vnh), hng dn ch n ung, sinh hot cho ngi x va thnh mch (b ht thuc l, vn ng ph hp) - Theo di kch thc ti phnh: siu m nh k mi 3-6 thng i vi ngi c ti phnh MC bng-chu nh, khi ng knh ngang ln th nhp vin m. i vi ngi c ti phnh ln nhng t chi m hay nguy c phu thut cao, khi c du hiu da v hay v u phi nhp vin ngay m cp cu. Ch nh phu thut mi nm au ti phnh Phnh MC hnh thoi > 40mm, hnh ti > 30mm Phnh M chu > 30mm Tc M chu-i Ti phnh da v v v % 5 15 2 2 36

Bn lun : Phnh MC bng di M thn iu tr ti BV Bnh Dn ngy cng nhiu v phc tp hn. a s c khi u bng, au. Nam nhiu hn n 4 ln, tui trung bnh l 64. Gn 50% c tn thng cc M khc. V ti phnh chim > 30%, l nguy c t vong hng u. Cc c im trn khng khc nhiu so vi phnh MC bng cc nc tin tin [2,5,8], tr ti phnh vim v tui b phnh tr hn. ci thin kt qu iu tr, cn can thip phu thut trc khi ti phnh v. Mun vy cn lm bnh n v theo di nh k tt c phnh MC bng c ch nh m kp thi. V ch nh phu thut, ngoi cc trng hp c bin chng, cn m ct-ghp MC cha triu chng khi ng knh ngang ti phnh hnh thoi > 40mm n, > 45mm nam. Nh ch nh ng v qun 19

l tt ngun bnh, t l m cp cu do v ti phnh gim t 60% thp nin 1980, xung cn 30% v t l bin chng, t vong cng gim mt na ti bnh vin chng ti [13,14],. V phu thut, khi c kinh nghim, c th ci tin nhiu cng on nh ng m bng nh, phu tch MC, M chu ti thiu, trnh gy tn thng m ri thn kinh giao cm h v, khng kp M chu b x cng vi ha, k thut ghp-to hnh bng ng ghp thng tit kim c ng ghp v ci thin t l bin chng v t vong rt ng k [13]. 2 nhm k thut iu phnh MC t xm ln l t stent v m ghp phnh MC qua ni soi c ng dng ti BV Bnh Dn t nm 2005, kt qu rt khch l [16]. Tuy nhin v stent-graft phi t hng nc ngoi mt nhiu thi gian v rt t tin nn cha c ng dng ph bin ti Vit Nam. V li khng phi trng hp no cng c th t stent-graft c. Cn phi xem xt k c ti phnh, trc c v ti phnh, trc ti phnh v cc M chu. Ring v m ghp MC qua ni soi bng hon ton, k thut thc hin c nhng mt nhiu thi gian, bc s phu thut ang c o to nn s bnh nhn c thc hin cha nhiu [16] nhng ni soi kt hp vi m m nh c thc hin v trin khai rng BV chng ti. Kt lun v khuyn co: Qua 30 nm iu tr phnh MC bng, thc tin v kinh nghim cho thy: 1. T l phnh MC bng nc ta thp (0,85%), a s l do x va thnh mch nhng s bnh nhn b MC bng + vim nhim c hiu (1% giang mai, lao) hay khng c hiu kh cao (15%). Phnh MC bng + hp cc M chu-i-cng chn v cc bnh nn phi, thn, mch vnh, mch cnh chim # 50% [13,16,17]. 2. gim bin chng, t vong do v ti phnh v chi ph iu tr nn m nhng ti phnh c ng knh t 45mm tr ln (c th so snh ng knh MC bng vi ng knh t sng trong lt ct CT scan m khng cn o: K/MC = hay > K t sng l c ch nh m [11] ) 3. Tt c ti phnh MC bng cha c triu chng au hay gy bin chng xa cn cho nhp vin v chp hnh MSCT, lm bnh n, cho xut vin iu tr ni khoa v theo di nh k da trn lm sng v siu m c hng iu tr thch hp. 4. M m ghp MC bng b phnh l phu thut kinh in ang c ng dng ph bin cc nc ang pht trin. 1 s ci tin phu thut gip n gin ho phu thut, gim gy bin chng v tit kim ng ghp [13]. 5. M ghp MC bng qua ni soi hon ton hay kt vi m m nh c th thc hin song song vi m m kinh in [13]. 6. t stent-graft MC bng nn c x dng cho nhng ngi m phu thut ni soi hay kinh in c nguy c cao [16]. Ti liu tham kho: 1- Castellani L, Angel F, Quillet L: Le risque cardiaque de la chirurgie des AAA. dans Les AAA sous rnaux. Actualits de chirurgie vasculaire, Edit AERCV, p 163-173.1990 2- Cooley DA: Surgical treatment of AA. 1986, edited by W.B. Saunders Company. 3- Cormier J.M.: Pathologie Vasculaire du sujet g. Lecture dans les 7me Journes dEchanges Vasculaires 8-9 Mai, 1998 , organises par lADVASE et lEcole de Mdecine de HCM ville. 4- Crawford E.S. et al (1981): AAA, factor influencing survival after operation performed over a 25 years period. Ann Surg. 1981,195,699-709. 5- De Bakey ME, Crawford ES et al: AAA; analysis of results of graft replacement therapy 1-11 years after operation. Ann Surg 160:622, 1964 6- Dubost C, Allary M et al: Resection of an AAA. Retablissement of the continuty by a preserved human arterial graft with result after 5 months. Arch Surg 64: 405, 1952 7- Ernst CB and Tyndall SH: AAA. Vascular Surgery. Copyright 1995 by Appleton and Lange, p 921-938 8- Gewertz BL, Schwartz LB: Surgery of the Aorta and its branches. Copyright 2000 by W.B. Saunders Company. 9- Huber TS, Osaki CK, Seeger JM: AAA. Surgery, 3th Edidition. Copyright 2001 by Lippincott Williams and Wilkins, p 1803-1833. 20

10- Kieffer E: Les AAA sous rnale. Actualits de chirurgie vasculaire. Editions AERCV 1990 11- Ouriel K and Green RM: Aneurysms in Arterial Disease. Principle of Surgery Schwartz, 7th Edition, Copyright 1999 by MCGraw-Hill Campagnies, p 938-948. 12- Parodi JC, Palmar JC, Barone HD: Transfemoral intraluminal graft implantation for AAA. Ann Vasc Surg 1991, 5: 491-499 13- Tan V et al: Progresses in treatment of AAA for the Vietnamese patients. The 3rd International Franco-Vietnamese 14- Tan V et al: Phnh MC bng di M thn: Tn sut v cc yu t nguy c qua kho st 4807 ngi >50 tui ti 24 qun-huyn, TP HCM. Tp ch Y hc VN. 328:180191,2006 15- Tan V et al: Xc nh kch thc trung bnh MC bng ngi dn >50 tui ti TPHCM qua siu m. Tp ch Y hc VN. 328192-205: , 2006. 16- Tan V, Cardon JM, De Soutter.P et al: KQ ban u T phnh MC bng di M thn qua t ng ghp ni mch. Tp ch Y hc VN. 328: 160-168,2006. 17- Tan V et al: Clinical characteristics, diagnosis, therapeutic indications, surgical techniques and early results. ti NC cp TP H Chi Minh, nghim thu nm 2006. Seminar on Medical and Surgical Cardio-Vascular Pathology. Viet Nam Hue 2005. Abstract 108, p133-134. 18- Testart J.: AAA. Lecture dans les VImes Journes d EPU Vasculaire; 29-30 Octobre 1997 a Ho Chi Minh ville. 19- Thinh CV, Tan V: AAA: Clinical characteristics, diagnosis, therapeutic indications, prognostic fators and early results. Ph.D thesis. HCM Medical School 2001. 20- Thompson M: Molecular mechanisms of aneurysm rupture. Abstract book 7th International Congress of the Asian Society of Vascular Surgery 2006, p 49. 21- Berge C, Hang ES, Romunstad PR et al: Infrarenal AAA repair. Time-trend durng a 20 year period. World J Surg 2007, 31(8), 1682-1686.

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