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 d-ới 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 (ch s huyt ỏp tõm thu c chõn trờn cỏnh tay) BMCD Bnh ng mch chi di BN Bnh nhõn M ng mch MV ng mch vnh DSA Chp mch s húa xúa nn T ỏi thỏo ng HA Huyt ỏp HDL-C Cholesterol t trng cao KCB6P Khong cỏch i b phỳt LDL-C Cholesterol t trng thp NMCT Nhi mỏu c tim NPB6P Nghim phỏp i b phỳt PAD Bnh ng mch ngoi biờn SA Siờu õm THA Tng huyt ỏp TM Tnh mch MC LC T VN Chng 1: TNG QUAN 1.1 Gii phu ng dng h ng mch chi di 1.1.1 Vựng chu 1.1.2 Vựng ựi 1.1.3 Vựng di khoeo 1.2 Bnh ng mch chi di 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 2: I TNG V PHNG PHP NGHIấN CU 41 2.1 i tng nghiờn cu 41 2.1.1 Tiu chun la chn bnh nhõn 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 46 2.2.5 Quy trỡnh can thip ni mch chi di 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 49 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 50 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 51 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 54 2.4 o c nghiờn cu 55 Chng 3: KT QU NGHIấN CU 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 57 3.1.3 Bnh lý phi hp 57 3.1.4 Phõn loi chõn b tn thng 58 3.1.5 Phõn loi tng tn thng 58 3.1.6 ỏnh giỏ TASC ca ngi bnh 59 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 60 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 64 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 68 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 70 Chng 4: 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 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 86 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 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 PH LC DANH MC BNG Bng 2.1 ỏnh giỏ mc au chõn theo phõn loi ca Fontaine v Rhutherford 48 Bng 2.2 Phõn loi mc hp theo Jager 50 Bng 2.3 Phõn loi v trớ tn thng M tng ch chu 51 Bng 2.4 Phõn loi tn thng M tng ựi khoeo theo TASC II 52 Bng 3.1: Mt s thụng tin chung v i tng nghiờn cu 56 Bng 3.2 Yu t nguy c 57 Bng 3.3 Bnh lý phi hp 57 Bng 3.4: Phõn loi tng tn thng 58 Bng 3.5 ỏnh giỏ TASC ca ngi bnh 59 Bng 3.6: So sỏnh kt qu ca siờu õm mch vi chp DSA 60 Bng 3.7: So sỏnh kt qu ca chp ct lp vi tớnh vi chp DSA 60 Bng 3.8: Mc au cỏch hi theo thang im Fontain trc v sau CT 61 Bng 3.9: Mc au cỏch hi theo thang im Rutherford 62 Bng 3.10 Phõn loi mc bnh ca ng mch theo ch s ABI 63 Bng 3.11 Giỏ tr ABI trc v sau can thip 63 Bng 3.12: ỏnh giỏ chp DSA trc v sau can thip 64 Bng 3.13: Khong cỏch i b ca ngi bnh trc v sau can thip 64 Bng 3.14: KCB6P trc v sau CT vi s chõn b hp/tc M 65 Bng 3.15: Khong cỏch i b trc v sau can thip vi mt s yu t nguy c 66 Bng 3.16: Hi chng chuyn húa v khong cỏch i b trc can thip 67 Bng 3.17: Khong cỏch i b v kt qu chp DSA l hp nng 68 Bng 3.18 Khong cỏch i b v kt qu chp DSA l tc hon ton 68 Bng 3.19 Khong cỏch i b v kt qu chp DSA 69 Bng 3.20: Khong cỏch i b trc can thip v tng tn thng 69 DANH MC BIU Biu 3.1: Phõn loi chõn b tn thng 58 Biu 3.2: Phõn b th thut can thip trờn cỏc i tng ngi bnh 59 Biu 3.3: Khong cỏch i b phỳt ca bnh nhõn BMCD trc v sau can thip 65 Biu 3.4: Tng quan gia khong cỏch bt u xut hin au cỏch hi v ch s ABI trc can thip 70 Biu 3.5: Biu 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5(3): 247-52 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 Rutherford Giai on Lõm sng Loi I Khụng triu chng 0 Khụng triu chng IIa au cỏch hi nh I au cỏch hi nh au cỏch hi va n nng I au cỏch hi va IIb I au cỏch hi nng II au chi ngh III Mt t chc ớt III Mt t chc nhiu III au chi ngh IV Loột hoc hoi t chi Cn lõm sng Nhp Sau can vin Glu HbA1c Cre CK A.uric CKMB Choles CRP HDL-c AST LDL-C ALT Tri Phi Chy trc Chy sau ABI Trỏi Chy trc Chy sau thip iu tr 4.1 Thuc O Aspegic mg/ngy O Plavix mg/ngy O cilostazol mg/ngy O Pentoxifillyl O Buflomedil 4.2 iu tr khỏc 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; O cú O khụng B thuc lỏ, lo: O B O Cũn hỳt ớt hn ch m: O Khụng b Kt qu CHA Siờu õm Hp m ch bng m chu chung T P m chu T P m chu ngoi T P m ựi chung T P Tc MSCT DSA Can thip T m ựi sõu P T m ựi nụng P T m khoeo P T m chy trc P T m chy sau P T m mỏc P Kt qu Test i b phỳt trc can thip Dc phm ó dựng trc th nghim (liu lng v thi gian): _ Oxy test: Khụng Bt u Cú: L / phỳt Kt thỳc Thi gian _: _ Nhp tim _ Khú th Mt mi SpO2 % _: _ _ % Ngng hoc tm dng trc phỳt? Khụng Cú lý do: Cỏc triu chng khỏc cui bui test: au tht ngc chúng mt hụng, chõn, hoc au bp chõn S vũng: (60 một) Tng khong cỏch i b phỳt: Khong cỏch d oỏn: _ Phn trm d oỏn: _% Kt qu Test i b phỳt sau can thip Dc phm ó dựng trc th nghim (liu lng v thi gian): Oxy test: Khụng Cú: L / phỳt Bt u Kt thỳc Thi gian _: _ Nhp tim _ Khú th Mt mi SpO2 % _: _ _ % Ngng hoc tm dng trc phỳt? Khụng Cú, lý do: _ Cỏc triu chng khỏc cui bui test: au tht ngc chúng mt hụng, chõn, hoc au bp chõn S vũng: (60 một) Tng khong cỏch i b phỳt: Khong cỏch d oỏn: _ Phn trm d oỏn: _% Kt cc lõm sng: T vong sau thỏng Tỏi nhp vin vỡ PAD - NMCT - SUYTIM - T QU- TI THễNG MCH VNH Ct ct au chi di cỏch hi ... 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]... nhiều phương pháp đi u trị BĐMCD khác như: đi u trị nội khoa, luyện tập có giám sát, can thiệp nội mạch, phẫu thuật bắc cầu động mạch chi dưới Trong can thiệp nội mạch dụng cụ qua da nhiều bác sỹ