B gio dc v o t0

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nghin cu Gi tr Ca phng php in quang can thip trong iu tr thng ng mch cnhxoang hang trc tip

B y t

NCS : Bi Vn Giang
Lun n tin s Y hc
Ngi hng dn khoa hc:

PGS. TS. phm minh thng gs. dng chm uyn

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T VN
- Thng ng mch cnh xoang hang trc tip (MCXH) khng him gp. - Thng gp cc nc ang pht trin. - Triu chng kinh in nh tai, li mt, cng t kt mc, nh hng nghim trng ti cuc sng i hi bin php iu tr trit , an ton

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T VN
-Trong qu kh: phu thut - phng php duy nht (nhc im: may ri, t l thnh cng hn ch bin chng thn kinh thm ch t vong...,)

- K thut in quang can thip (TG: thp k 70):

+ thay i cch iu tr thng MCXH

+ thay i tin lng ca bnh l ny

- Vit nam: t 1999

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Mc tiu nghin cu 1. nh gi gi tr ca phng php in quang can thip trong iu tr thng ng mch cnh - xoang hang trc tip. 2. xut ch nh k thut iu tr ni mch i vi cc th thng ng mch cnh - xoang hang trc tip .

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Tng quan
C s gii phu phc hp xoang hang

Hashimoto, M., Neurol Med Chir, 2000. 40(3): p. 140-50

ng dng trong iu tr

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Tng quan
Chn on thng ng mch cnh xoang hang Triu chng lm sng
- TAI - LI MT - CNG T KT MC

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Tng quan
Chn on thng ng mch cnh xoang hang Siu m Doppler

tnh mch mt:

gin, o chiu, ng mch ha dng chy

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Tng quan
Chn on thng ng mch cnh xoang hang Chp ct lp vi tnh hoc chp cng hng t

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Tng quan
Chn on thng ng mch cnh xoang hang Chp mch theo k thut Seldinger Chn on xc nh nh gi mc

Tn thng phi hp, phn bit

Can thip iu tr

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Tng quan
Lch s cc phng php iu tr thng MCXH Cc phng php ngoi khoa

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k thut brooks

Vit nam:
L xun trung, nguyn thng xun Trng vn vit

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Th thut brooks ci tin

-T l thnh cng 85% -T l t vong 1%, lit 1/2 ngi 2%, ti pht 12%.

Trng Vn Vit, Y hc thnh ph H ch Minh, tp 6, bn ph san s 1, 2002. p 40-45

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Tng quan
Lch s cc phng php iu tr thng MCH Cc phng php nt mch - Bng bng tch ri - Bng cun kim loi (coil) - Bng cc vt liu khc

K thut Serbinenko-1971

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Tng quan

Bng tch ri Cun kim loi

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i tng v phng php

i tng nghin cu
Tiu chun la chn: - C hnh nh chp mch xc nh thng ng mch cnh xoang hang trc tip. - c nt mch ti khoa CHA bnh vin Bch mai. - c theo di t nht 01 tun sau th thut hoc c bin chng lin quan.

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i tng v phng php

i tng nghin cu
Tiu chun loi tr : - Thng ng tnh mch mng cng (fistule durale) n thun vng xoang hang. - Khng c iu tr bng phng php nt mch.

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i tng v phng php

Phng php nghin cu M t tin cu Qui trnh k thut nh gi kt qu trong th thut, sau th thut

X l s liu: SPSS

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i tng v phng php

C mu:

n=

pq 2 d

n : C mu nghin cu ti thiu. Z(1- /2) : l h s gii hn tin cy. chn = 0,05 - tin cy 95%, gi tr ca h s gii hn tin cy Z(1- /2) =1,96 p : T l kt qu mong mun. q= 1 - p d: chnh xc mc tin cy 1- : mc xc sut sai lm

= 0,05
= 0,01

n= 1,962x0,88x0,12 / 0,12 = 41

n= 2,582x0,88x0,12 / 0,12 = 71

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i tng v phng php

Phn lu lng thng MCXH

A: Lu lng thng rt ln

B: Lu lng thng va

C: Lu lng thng thp

Hnh 2.1: Phn loi lu lng thng trn phim chp mch

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i tng v phng php

Phn dn xoang tnh mch hang

A: Dn ln > 3 ln ng knh ng mch

B: Dn va 2-3 ln ng knh ng mch

C: Dn nh, <2 ln ng knh ng mch

Hnh 2.2: Phn loi mc dn tnh mch hang

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i tng v phng php

- nh gi kt qu trn hnh chp mch + Bt hon ton ch thng. + Khng hp lng ng mch cnh.

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i tng v phng php

- nh gi kt qu trn hnh chp mch + Bt hon ton ch thng. + Gy tc lng ng mch cnh.

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i tng v phng php

- nh gi kt qu trn hnh chp mch + Khng gy tc hon ton c l thng nhng lu lng thng cn rt nh. (Du hiu th hin lu lng thng cn nh: - Tnh mch xoang hang hin hnh mun. - C hin tng lu thuc trong xoang hang.)

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i tng v phng php

- nh gi kt qu trn hnh chp mch + Tht bi: lung thng cn ln.

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i tng v phng php

Thng k bin chng: - Tc mch. - Hp lng mch. - Huyt khi tnh mch. V mt lm sng: - T vong, lit 1/2 ngi. - Lit thn kinh trung ng. - Lit cc dy thn kinh s nht l cc dy vn nhn.

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Kt qu

T 11 nm 1999 ti 5 nm 2008 c 206 bnh nhn

Mt s c im ca mu nghin cu
60 50

49

25%
40

32
30

25
20

26 18 19 20

Nam N

10

75%
1 1
6-10

0 0-5 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 tren 60

Tui trung bnh 32,6 12,6 16-50 tui, tui hot ng nhiu. 91,8%

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Kt qu

c im ca mu nghin cu

Lu lng thng 1 Lu lng thng rt ln

S lng 75

T l % 36,4

2
3

Lu lng thng va
Lu lng thng thp

101
30

49
14.6

Tng s

206

100 %

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Kt qu

c im tn thng

Mc dn XTMH
1 2 3 Rt ln (>3 ln k DM cnh) Va (2-3 ln k DM cnh) Nh (<2ln k DM cnh) Tng s

S lng T l
32 94 80 206 15,5 45,6 38,9 100%

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Biu 3.3: Kt qu nt mch khi chp kim tra cui th thut

H thng, bo tn t lng m ch, 145, 71%

H thng, bo tn lng m ch t H thng, t m ch cnh t c Cn thng, l- u l- ng thp Cn thng, l- u l- ng cao (tht b i) Kh c

Kh c, 3, 1% Cn thng, l- u l- ng cao (tht b i), 6, 3%

Cn thng, l- u l- ng thp, 13, 6%

H thng, t t c m ch cnh, 39, 19%

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Kt qu, bn lun

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Kt qu, bn lun

Bng 3.16: Cc vt liu nt trn bnh nhn nt mch ln mt

Vt liu Bng+coil, nt Coil,Bng tch1% 11, 2, ri 5% Cun kim loi

Bng + ht nha Bng + keo (Histoacryl) Cc vt Onyx) liu khc

S lng Bng+hat; 192 1; 0,5% 11

1 2 (stent, 0

T l %
93,2 5,3
Bng 0,5 Coil 1 Bng+coil Bng+hat 0

Tng s Bng, 192, 94%

206

100 %

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Kt qu, bn lun

Trc nt Sau nt 24h

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Kt qu, bn lun

Sau nt mch 24h Trc nt

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Vn nt hon ton ng mch cnh: -Chp kim tra vng ni.

-Th nt 30 pht, theo di lm sng

Kt qu: bin chng 0%

Trc nt thng mcxh

sau nt M cnh

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Kt qu, bn lun
-V tr nt mch: - Trn + di ch thng - Khng gy tc ng mch mt

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Kt qu, bn lun
Nguyn nhn ti pht: -Tut v tr bng -Tn thng phi hp

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Kt qu, bn lun
Bin chng: Bin chng
1
2 3 4 5

S lng

T l %

Ti pht
Lit (do th thut) T vong M mt Huyt khi tnh mch Tng s

20
0 0 0 1 21

9,7
0 0 0 0,5 10,2

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Kt qu, bn lun

c im tn thng
Mc dn XTMH Lu lng thng DMCXH

Dn nhiu 25

Dn va 41

Dn t 13

Tn g s 79

Lu lng rt ln

Lu lng va
Lu lng thp Tng s

7 0
32

49 4
94

43 24
80

99 28
206

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Kt qu

Bng 3.10: Tng quan gia lu lng thng vi dn XTMH mc ln v nh

Mc dn XTMH Lu lng thng Thng lu lng rt ln Cc mc thng khc Tng s

Mc Tng Dn ln dn t s hn 25 7 32 54 120 174 79 127 206

OR: 7.94, 95% CI: 3.03-21.61

lin quan cht ch gia lu lng thng v mc dn tnh mch xoang hang vi OR=7,94. T l xut hin dn ln ca nhm thng lu lng ln cao gp 7.9 ln. (p< 0.001)

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Bng 3.12: Tn thng phi hp

1 2 3 4 5

Tn tn thng phi hp Tc ng mch cnh trong Thng ng-tnh mch mng cng Gi phnh ng mch Phnh ng mch V xng Tng s

S lng 7 4 5 1 2 206

T l % 3,4% 1,9% 2,4% 0,5% 1% 9,2%

Gi phnh ng mch

2,4%

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Kt qu, bn lun

Bng 3.17: Lin quan gia lu lng thng v vt liu nt mch

Vt liu nt mch Lu lng thng Lu lng rt ln Lu lng ln Lu lng thp Tng s Bng 72 98 22 192 Cun kim loi 3 3 5 11 Vt liu khc 0 0 3 3 Tng s 75 101 30 206

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Kt qu, bn lun

Bng 3.19: Lin quan gia lu lng thng rt ln, ln v vt liu nt Vt liu nt mch Cc vt Tng Bng liu s khc Lu lng thng Thng lu lng rt ln v va 170 6 176 Thng lu lng thp Tng s 22 8 30

192

14

206

OR= 10,3, 95% CI: 2,89-37,65

Lin quan rt cht ch gia lu lng cao v vt liu s dng nt mch vi OR=10,3. T l xut s dng bng nt mch ca nhm thng lu lng rt ln v ln cao gp 10.3 ln so vi t l s dng bng nt mch ti nhm lu thng thp. (p< 0.001).

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Kt qu, bn lun
Ch nh phng php: -Lin quan gia lu lng v vt liu

-ng vo can thip

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Kt qu, bn lun
Ch nh phng php: -Lin quan gia lu lng v vt liu -ng vo can thip

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Kt qu, bn lun

Bng 3.20: Lin quan gia vt liu v kt qu nt mch

Kt qua chp mch kt thc th thut Ht thng, bao tn lng DM canh Bng Vt liu khc Tng 140 5 145 Ht thng, tc DM canh 34 5 39 Cn thng, lu lng thp 10 3 13 Cn thng lu lng cao 6 0 6 Tn g

Khc

2 1 3

192 14 206

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Kt qu, bn lun

Bng 3.21: Tng quan gia vt liu nt mch vi kt qu tt

Kt qu Lu lng thng Ht thng, bo tn lng DM cnh Cc dng kt qu khc Tng s

Bng
Vt liu khc Tng s

140
5 145

52
9 61

192
14 206

OR= 4,8; 95% CI: 1,5-15,1

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Kt qu, bn lun

Bng 3.22: Lin quan gia mc dn xoang hang v vt liu nt

Vt liu nt Vt liu nt mch Bn Cun Bng Bn g kim +CKL g loi +keo Tn g Bng + ht

Mc dn XTMH

Dn ln
Dn va

29
93

3
1

0
0

0
0

32
94

Dn nh
Tng

70
192

6
10

1
1

2
2

1
1

80
206

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Bng 3.23: Tng quan gia mc dn XTMH v vt liu nt l bng
Vt liu nt Mc dn XTMH XTMH dn ln v va Ch dng bng 122 Vt liu khc 4 Tng s

Kt qu, bn lun

126

XTMH dn nh
Tng s

70
192

10
14

80
206

OR: 4,36; 95% CI: 1,2-17,21

Nh vy c mi quan h cht ch gia mc dn xoang hang vi vt liu nt l bng vi OR = 4,36.

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Vt liu nt: Bng: -R, hiu qu -T xp Cun kim loi: -t

-Lung thng nh
-ng tnh mch Stent kn: -Bo tn lng mch Keo, ht nha: -Phi hp

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Kt lun

1.Gi tr ca cc phng php in quang can thip nt mch - Nt hon ton v tr thng, bo ton c lng
ng mch 71%: - Bt hon ton ch thng nhng phi gy tc lng ng mch cnh 19%. - Khng c bin chng nng (lit na ngi, t vong). - Cc trng hp nt tht bi ln u v ti pht c nt li cc ln tip theo v t l thnh cng chung l 98% .

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Kt lun

2. Ch nh phng php nt mch ph thuc vo dng tn thng

- Bng lun c th trong mi trng hp v c kh nng thnh cng trong trng hp xoang cnh dn va v lung thng khng qu nh bng c th qua c l rch.

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Kt lun

2. Ch nh phng php nt mch ph thuc vo dng tn thng

- Nt hon ton ng mch cnh trong (sau

nghim php nt th an ton) l ch nh hp l trong cc trng hp lung thng rt ln, xoang hang dn ln > 3 ln ng knh ng mch. - Khi khng c ng vo t ng mch cnh trong th phng php dng cun kim loi l gii php tt gip i n c xoang hang v nt l thng.

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Xin trn trng cm n