Đánh giá hiệu quả của can thiệp nội mạch qua da ở bệnh nhân bị bệnh động mạch chi dưới mạn tính bằng nghiệm pháp đi bộ 6 phút

B Y T TRNG I HC Y H NI V XUN TUN Đánh giá hiệu can thiệp nội mạch qua da bệnh nhân bị bệnh động mạch chi dới MạN TíNH nghiệm pháp phút Chuyờn ngnh : Ni Tim Mch Mó s : CK 62722025 LUN VN BC S CHUYấN KHOA CP II Ngi hng dn khoa hc: PGS.TS Nguyn Lõn Hiu H NI 2016 LI CM N Lun ny c hon thnh bng s n lc ca tụi v s giỳp ca nhiu cỏ nhõn v th Nhõn dp hon thnh lun ny vi lũng kớnh trng v bit n, tụi xin c by t lũng cm n ti: Ban Giỏm hiu trng i hc Y H Ni, Ban Giỏm c bnh vin Bch Mai, Ban Giỏm c Vin Tim mch Quc gia, Ban Giỏm c Bnh vin Bu in, B mụn Ni, B mụn Tim mch, Phũng o to Sau i hc ó to mi iu kin thun li cho tụi sut quỏ trỡnh nghiờn cu v hon thnh lun ny Tụi xin t lũng bit n sõu sc ti PGS.TS Nguyn Lõn Hiu, ging viờn trng i hc Y H Ni, ngi thy khụng ch ó trc tip hng dn tụi quỏ trỡnh lm lun m cũn luụn ch bo, dy d, to mi iu kin tt nht cho tụi quỏ trỡnh hc Tụi xin c gi li cm n ti th bỏc s, iu dng, cỏc bn hc viờn ang cụng tỏc v hc ti Vin tim mch Quc gia ó luụn giỳp , ng viờn gúp ý cho tụi quỏ trỡnh hc v nghiờn cu Tụi xin c gi li cm n ti th cỏn b, y bỏc s bnh vin Bu in ó giỳp tụi quỏ trỡnh hon thnh lun ny Cui cựng vi lũng bit n sõu sc nht tụi xin gi li cm n ti gia ỡnh, v v cỏc ca tụi, h l ch da vng chc v l ngun ng lc to ln giỳp tụi bc i lờn ng s nghip ca mỡnh Mt ln na tụi xin trõn trng cm n! H Ni, ngy 10 thỏng 12 nm 2016 V Xuõn Tun LI CAM OAN Tụi l V Xuõn Tun, hc viờn CKII khúa 28, chuyờn ngnh Ni Tim mch, Trng i hc Y H Ni xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Nguyn Lõn Hiu Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 10 thỏng 12 nm 2016 Ngi vit cam oan V Xuõn Tun CH VIT TT ABI Ankle- Brachial index BMCD BN M MV DSA T HA HDL-C KCB6P LDL-C NMCT NPB6P PAD SA THA TM (ch s huyt ỏp tõm thu c chõn trờn cỏnh tay) Bnh ng mch chi di Bnh nhõn ng mch ng mch vnh Chp mch s húa xúa nn ỏi thỏo ng Huyt ỏp Cholesterol t trng cao Khong cỏch i b phỳt Cholesterol t trng thp Nhi mỏu c tim Nghim phỏp i b phỳt Bnh ng mch ngoi biờn Siờu õm Tng huyt ỏp Tnh mch MC LC T VN TNG QUAN 1.1 Gii phu ng dng h ng mch chi di 1.1.1 Vựng chu 1.1.2 Vựng ựi .4 1.1.3 Vựng di khoeo 1.2 Bnh ng mch chi di .7 1.2.1 Khỏi nim 1.2.2 C ch bnh sinh 1.3 Dch t hc 1.3.1 Yu t nguy c 1.3.2 Tn sut mc bnh ng mch chi di 15 1.4 Chn oỏn 18 1.4.1 Triu chng lõm sng .18 1.4.2 Thm dũ Cn lõm sng .19 1.5 Nghim phỏp i b phỳt 25 1.6 iu tr 32 1.6.1 iu chnh cỏc yu t nguy c tim mch 32 1.6.2 iu tr triu chng au cỏch hi chi di .32 1.6.3 iu tr thiu mỏu chi di trm trng .35 1.7 iu tr BMCD bng can thip ni mch qua da .37 Chng 41 I TNG V PHNG PHP NGHIấN CU 41 2.1 i tng nghiờn cu 41 Bao gm cỏc bnh nhõn c chn oỏn BMCD, c can thip qua da ng mch chi di ti Vin Tim mch Vit Nam 41 2.1.1 Tiu chun la chn bnh nhõn 41 - Cỏc bnh nhõn c chn oỏn BMCD theo tiờu chun ca ACC/AHA 2005, cp nht nm 2011 [53] .41 - Cú ch nh tỏi ti mỏu bng can thip M chi di qua da theo khuyn cỏo ca Hi Tim Mch hc Vit nam 2010 v cỏc bnh lý Tim mch v Chuyn húa (bao gm BMCD cú triu chng au cỏch hi v BMCD cú triu chng thiu mỏu chi di trm trng) .41 2.1.2 Tiờu chun loi tr bnh nhõn 41 2.1.3 a im v thi gian nghiờn cu 42 2.2 Phng phỏp nghiờn cu 42 2.2.1 Thit k nghiờn cu 42 2.2.2 Quy trỡnh thc hin nghim phỏp i b phỳt 43 2.2.3 Quy trỡnh siờu õm Doppler h M chi di: 45 2.2.4 Quy trỡnh chn oỏn tn thng ca h thng M chi di trờn chp CLVT [88] 46 2.2.5 Quy trỡnh can thip ni mch chi di [89] .46 2.3 Cỏc thụng s nghiờn cu .48 2.3.1 Thụng tin chung: Tui, gii, chiu cao, cõn nng, BMI 48 2.3.2 Tin s: .48 2.3.3 Cỏc tiờu chun ỏnh giỏ triu chng lõm sng 48 2.3.4 Phõn loi hi chng chuyn húa 48 2.3.5 Phõn loi mc thiu mỏu chi theo ch s ABI .49 2.3.6 Phõn loi tn thng ng mch trờn siờu õm Doppler 49 2.3.7 Phõn loi mc tn thng ng mch trờn chp ct lp vi tớnh v chp DSA 50 2.3.8 Phõn loi hỡnh thỏi ca tn thng trờn phim chp DSA 50 2.3.9 Phõn loi tng tn thng ng mch 52 2.3.10 Kt qu Test i b phỳt trc v sau can thip 53 2.3.11 Mt s thụng s v can thip 53 2.4 o c nghiờn cu 55 KT QU NGHIấN CU 56 Nghiờn cu ca chỳng tụi thc hin trờn 60 bnh nhõn c chn oỏn Bnh ng mch chi di, c can thip qua da ng mch chi di ti Vin Tim mch Quc gia t thỏng 10/2015 n thỏng 10/2016 Kt qu nghiờn cu c trỡnh by theo cỏc ni dung sau: .56 3.1 c im chung ca nhúm nghiờn cu .56 3.1.1 Tui, gii v ch s BMI 56 3.1.2 Yu t nguy c 56 3.1.3 Bnh lý phi hp 57 3.1.4 Phõn loi chõn b tn thng 57 3.1.5 Phõn loi tng tn thng 58 3.1.6 ỏnh giỏ TASC ca ngi bnh .58 3.1.7 Phõn b th thut can thip trờn cỏc i tng ngi bnh .59 3.1.8 So sỏnh kt qu ca siờu õm mch vi chp DSA 59 3.1.9 So sỏnh kt qu ca chp ct lp vi tớnh vi chp DSA 60 3.2 ỏnh giỏ hiu qu can thip ng mch chi di .61 3.2.1 Mc au cỏch hi theo thang im Fontain trc v sau can thip 61 3.2.2 Mc au cỏch hi theo thang im Rutherford trc v sau CT 62 3.2.3 ỏnh giỏ giỏ tr ABI trc v sau can thip .63 3.2.4 ỏnh giỏ chp DSA trc v sau can thip 63 3.2.5 Khong cỏch i b phỳt ca ngi bnh trc v sau can thip 64 3.3 Mi liờn quan gia giỏ tr ca NPB6P vi mt s thm dũ cn lõm sng khỏc .65 3.3.1 Liờn quan KCB6P trc v sau can thip vi s chõn b hp/tc M 65 3.3.2 Liờn quan gia khong cỏch i b trc v sau can thip vi mt s yu t nguy c 66 3.3.3 Liờn quan gia khong cỏch i b trc can thip vi Hi chng chuyn húa 67 3.3.4 Liờn quan gia khong cỏch i b trc can thip vi DSA 67 3.3.5 Liờn quan gia khong cỏch i b trc can thip theo tng tn thng 69 3.3.6 Tng quan gia khong cỏch i b vi ch s ABI 69 Chng 73 BN LUN 73 4.1 c im chung ca i tng nghiờn cu 73 4.1.1 V tui, gii 73 4.1.2 Yu t nguy c 74 4.1.3 c im v cỏc bnh lý mch mỏu khỏc kốm theo 80 4.1.4 Phõn loi tn thng theo tng 81 4.1.5 Phõn loi TASC II cỏc tn thng c can thip 82 4.1.6 So sỏnh kt qu ca siờu õm mch vi chp DSA 83 4.1.7 So sỏnh kt qu ca chp ct lp vi tớnh vi chp DSA 83 Tng t nh siờu õm, trờn phim chp ct lp vi tớnh mch chi di, chỳng tụi so sỏnh gia chp ct lp vi tớnh vi chp DSA (l tiờu chun vng) chn oỏn mc hp tc ca ng mch chi di Kt qu ca nghiờn cu ca chỳng tụi cho thy chp ct lp vi tớnh cú nht quỏn mc cao so vi DSA vi h s Kappa = 0,674 vi p < 0,05 iu ny th hin ch s Kappa thc s khỏc bit vi giỏ tr tc l s nht quỏn ny cú tn ti Tuy nhiờn so sỏnh vi cỏc tỏc gi khỏc gia kt qu chp ct lp vi tớnh vi chp DSA thỡ h s Kappa ca cỏc tỏc gi Catalano et al l v Ota et al l 0,97 , gii thớch s chờnh lch ny chỳng tụi nhn thy: nghiờn cu, chỳng tụi ch ỏnh giỏ n cỏc tn thng nng cú nh hng trc tip n chc nng ca chi di cn phi can thip m khụng tớnh n cỏc tn thng mc nh hn Mt khỏc, cỏc bnh nhõn n vi chỳng tụi thng giai on mun, nhiu tn thng phi hp, mn tớnh, thnh mch b vụi hoỏ nhiu phn no ó nh hng n kt qu chp ct lp vi tớnh 83 4.2 ỏnh giỏ hiu qu can thip ng mch chi di .84 4.2.1 Hiu qu can thip ng mch chi di theo phõn loi giai on thiu mỏu ca Fontain v Rutheford 84 4.2.2 Ch s ABI trc v sau can thip 85 4.2.3 ỏnh giỏ chp DSA trc v sau can thip 85 4.2.4 Khong cỏch i b phỳt trc v sau can thiờp 86 4.3 Mi liờn quan gia giỏ tr ca nghim phỏp i b phỳt 88 Vic chn oỏn sm bnh ng mch chi di l khú khn vỡ hu ht bnh khụng cú triu chng nhiu nm Cỏc triu chng ch xut hin lũng ng mch hp ớt nht 50%, s ny ch cú 10% cú du hiu au cỏch hi Vic chn oỏn sm, c bit l s dng cỏc bin phỏp khụng xõm ln l cú ý ngha quan trng [60],[47] .88 4.3.1 Liờn quan KCB6P trc v sau can thip vi s chõn b hp/tc M 89 4.3.2 Liờn quan gia khong cỏch i b trc can thip vi mt s yu t nguy c 90 4.3.3 Liờn quan gia khong cỏch i b trc can thip vi kt qu chp DSA 91 4.3.4 Liờn quan gia khong cỏch i b phỳt vi ch s ABI 92 KT LUN 98 KIN NGH 99 TI LIU THAM KHO 100 PH LC 32 Bowers BL, Valentine RJ, Myers SI, et al (1993), The natural history of patients with claudication with toe pressures of 40 mm Hg or less, J Vasc Surg; 18: 506-11 33 Skinner JJ, et al (1985) Intermittent claudication: incidence in the Framingham Study, Circulation, 41: 875-883 34 Maca T, Mlekusch W, et al (2007), Influence and interaction of diabetes and lipoprotein (a) serum levels on mortality of patients with Peripheral Artery Disease, European Journal of Clinical Investigation, 37:180-186 35 Murabito JM, DAgostino RB, Silbershatz H, et al (1997), Intermittent claudication A risk profile from The Framingham Heart Study, Circulation; 96: 44-9 36 Newman AB, Siscovick DS, Manolio TA, et al (1993), Ankle-arm index as a marker of 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5(3): 24752 BNH N NGHIấN CU (S: .) 1.Thụng tin chung: Mó BA: Ngy v/v: / / H tờn BN: Ngy r/v: / / Tui: a ch: Gii:O nam O n T liờn lc: Chiu cao: (cm) Cõn nng: (kg) Tin s v cỏc yu t nguy c 2.1 THA Thi gian phỏt hin: (nm) Thuc iu tr: Tuõn th iu tr: O u O khụng u O khụng tr HA max: HA nn: 2.2 Hỳt thuc lỏ S iu hỳt tb/ngy: Thi gian hỳt thuc lỏ: 2.3 Hỳt thuc lo S iu/ngy: S ngy ht 100g: Thi gian hỳt thuc: 2.4 ỏi thỏo ng S nm c chn oỏn: HbA1c trung bỡnh: 2.5 Tin s bnh lý ng mch x va Bnh mch vnh Mch cnh Mch thn 2.6 Tin s ri loan lipid mỏu 2.7 Tin s gia ỡnh b bnh tim mach Triu chng lõm sng Fontaine Giai on Lõm sng I Khụng triu chng IIa au cỏch hi nh Rutherford IIb au cỏch hi va n nng III au chi ngh IV Loột hoc hoi t chi Loi 0 Khụng triu chng I au cỏch hi nh I au cỏch hi va I au cỏch hi nng II au chi ngh III Mt t chc ớt III Mt t chc nhiu Cn lõm sng Nhp Sau can vin Glu Cre A.uric Choles HDL-c LDL-C Tri HbA1c CK CKMB CRP AST ALT ABI thip Phi Chy trc Chy sau Trỏi Chy trc Chy sau iu tr 4.1 Thuc O Aspegic mg/ngy O Plavix O cilostazol mg/ngy O Pentoxifillyl 4.2 iu tr khỏc mg/ngy O Buflomedil Kim soỏt ng huyt: Kim soỏt lipid mỏu: O Insulin O Metformin O sulfunylure O khỏc O statin O fibrat Kim soỏt HA: O chn calci O CMC Luyn tp: O ớt O khụng O CTT O chn beta O Ch n: n nhiu rau qu: O cú O khụng; 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Đánh giá hiệu can thiệp nội mạch qua da bệnh nhân bị bệnh động mạch chi mạn tính nghiệm pháp phút với mục tiêu: Đánh giá hiệu can thiệp nội mạch qua da bệnh nhân bị bệnh động mạch chi mạn tính. .. hiện, phù hợp với bệnh nhân cao tuổi, bệnh nhân khả thực nghiệm pháp gắng sức để đánh giá hiệu đi u trị can thiệp bệnh nhân bệnh lý tim mạch nói chung, có can thiệp mạch máu chi nói riêng [1]... thực 60 bệnh nhân chẩn đoán Bệnh động mạch chi dưới, can thiệp qua da động mạch chi Viện Tim mạch Quốc gia từ tháng 10/2015 đến tháng 10/20 16 Kết nghiên cứu trình bày theo nội dung sau: . 56 3.1