Nghiên cứu đặc điểm lâm sàng, cận lâm sàng và kết quả điều trị bệnh nhân tăng huyết áp có hẹp động mạch thận bằng phương pháp can thiệp qua da

B GIO DC & O TO B QUC PHềNG VIN NGHIấN CU KHOA HC Y DC LM SNG 108 Lấ VN CNG NGHIÊN CứU ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG Và KếT QUả ĐIềU TRị Bệnh nhân tăng huyết áp có HẹP Động mạch thận Bằng phương pháp can thiệp qua da LUN N TIN S Y HC H NI 2017 B GIO DC & O TO B QUC PHềNG VIN NGHIấN CU KHOA HC Y DC LM SNG 108 Lấ VN CNG NGHIÊN CứU ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG Và KếT QUả ĐIềU TRị Bệnh nhân tăng huyết áp có HẹP Động mạch thận Bằng phương pháp can thiệp qua da Chuyờn ngnh: Ni tim mch Mó s: 62.72.01.41 LUN N TIN S Y HC HNG DN KHOA HC: PGS.TS Phm Mnh Hựng PGS.TS V in Biờn H NI 2017 LI CM N hon thnh lun ỏn tụi xin trõn trng cm n: - B mụn Tim mch, Phũng Sau i hc, Ban giỏm c Bnh Vin Trung ng quõn i 108 - Vin nghiờn cu khoa hc Y dc lõm sng 108 ó to iu kin thun li cho tụi quỏ trỡnh hc v nghiờn cu - PGS.TS Phm Mnh Hựng, Phú Vin trng Vin Tim mch Bnh vin Bch Mai trc tip hng dn, luụn tn tỡnh giỳp tụi quỏ trỡnh hc tp, nghiờn cu v cụng tỏc - PGS.TS V in Biờn, ch nhim b mụn Tim Mch - Bnh vin Trung ng Quõn i 108 ó trc tip hng dn, tn tỡnh dy d, to iu kin thun li cho tụi hon thnh lun ỏn - PGS.TS Phm Nguyờn Sn, Phú Ch nhim B mụn Tim mch, Phú Giỏm c - Bnh vin Trung ng Quõn i 108 ó to iu kin cho tụi hc v luụn a nhng gúp ý b ớch quỏ trỡnh hon thnh nghiờn cu - PSG.TS Lờ Vn Trng, Vin trng Vin Tim mch Bnh vin Trung ng Quõn i 108, luụn to iu kin v cú nhiu ý kin quớ bỏu quỏ trỡnh hon thnh nghiờn cu - PGS.TS Nguyn Ngc Quang, B mụn Tim mch, Trng i hc Y H Ni ó tn tỡnh hng dn tụi thc hin cỏc k thut can thip Tim mch v cú nhiu ý kin úng gúp giỳp tụi hon thnh nghiờn cu - TS Phm Thỏi Giang, cỏc ging viờn B mụn Tim mch, Phũng Sau i hc Vin Nghiờn cu khoa hc Y Dc lõm sng 108 ó giỳp tụi hc tp, cụng tỏc, giỳp tụi hon thnh lun ỏn ny - Ban lónh o Vin Tim mch Bnh vin Bch mai, th y bỏc s phũng Siờu õm, cỏc phũng iu tr, phũng can thip, phũng k hoch tng hp ó giỳp v to iu kin cho tụi quỏ trỡnh hc v nghiờn cu - Lónh o S Y t, Bnh vin a khoa tnh, Khoa Hi sc tớch cc v cỏc khoa phũng - Bnh vin a khoa tnh Thanh Húa 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cu v ngoi nc v iu tr hp ng mch thn 28 1.4.1 Mt s nghiờn cu trờn th gii 28 1.4.2 Mt s nghiờn cu Vit Nam 33 CHNG I TNG V PHNG PHP NGHIấN CU 35 2.1 i tng nghiờn cu 35 2.1.1 Tiờu chun la chn bnh nhõn .35 2.1.2 Tiờu chun loi tr 35 2.1.3 Thi gian v a im nghiờn cu 36 2.2 Phng phỏp nghiờn cu .36 2.2.1 Thit k nghiờn cu .36 2.2.2 Chn mu nghiờn cu 36 2.2.3 Phng tin nghiờn cu 36 2.2.4 Cỏc bc tin hnh nghiờn cu .38 2.2.5 K thut khng ch sai s 55 2.2.6 X lý s liu .55 2.2.7 o c nghiờn cu 56 CHNG KT QU NGHIấN CU 58 3.1 c im chung ca nhúm nghiờn cu 58 3.1.1 c im nhõn trc 58 3.1.2 c im v tin s ca bnh nhõn 61 3.2 Lõm sng v cn lõm sng ca nhúm nghiờn cu 62 3.2.1 Triu chng lõm sng 62 3.2.2 Cn lõm sng 67 3.3 Kt qu can thip ng mch thn qua da 72 3.3.1 Cỏc thụng s liờn quan n k thut can thip 72 3.3.2 Kt qu sm sau can thip 76 3.3.3 Kt qu theo dừi dc theo thi gian 78 CHNG BN LUN 92 4.1 c im chung ca nhúm nghiờn cu 92 4.1.1 c im v nhõn trc 92 4.1.2 c im v tin s .93 4.2 c im lõm sng v cn lõm sng ca bnh nhõn nghiờn cu 95 4.2.1 c im lõm sng 95 4.2.2 c im cn lõm sng 99 4.3 Kt qu can thip ng mch thn qua da 102 4.3.1 V k thut can thip ng mch thn 102 4.3.2 Kt qu sm sau can thip ng mch thn 105 4.3.3 Kt qu theo dừi dc sau can thip ng mch thn 109 KT LUN 127 c im lõm sng v cn lõm sng 127 1.1 c im lõm sng 127 1.2 c im cn lõm sng 127 Kt qu can thip ng mch thn qua da 128 2.1 T l thnh cụng v cỏc bin chng sm 128 2.2 Theo dừi sau can thip thỏng 128 KI N NGH 129 TI LI U THAM KHO DANH SCH BNH NHN NGHIấN CU DANH MC BNG Trang Bng 2.1 Thuc h huyt ỏp c tớnh theo liu c s 40 Bng 2.2 Phõn tng huyt ỏp ca Hi Tim mch hc Vit Nam .52 Bng 3.1 T l gii ca nhúm nghiờn cu .58 Bng 3.2 Tui trung bỡnh ca nhúm nghiờn cu 59 Bng 3.3 Phõn nhúm tui theo gii ca nhúm nghiờn cu .59 Bng 3.4 Ch s c th ca nhúm nghiờn cu 60 Bng 3.5 Tin s ca nhúm nghiờn cu 61 Bng 3.6 Cỏc triu chng c nng ca nhúm nghiờn cu 62 Bng 3.7 c im huyt ng ca nhúm nghiờn cu 63 Bng 3.8 c im v ch s huyt ỏp trc can thip 64 Bng 3.9 c im tui phỏt hin tng huyt ỏp 64 Bng 3.10 c im thi gian tng huyt ỏp 65 Bng 3.11 c im huc h huyt ỏp ca nhúm nghiờn cu 66 Bng 3.12 Cỏc xột nghim c bn ca nhúm nghiờn cu 67 + Bng 3.13 T l h nng K mỏu ca nhúm nghiờn cu .68 Bng 3.14 Cỏc thụng s trờn siờu õm Doppler ng mch thn 69 Bng 3.15 c im tn thng ng mch thn trờn DSA .71 Bng 3.16 Cỏc thụng s dõy dn, búng v stent .74 Bng 3.17 Cỏc k thut can thip ng mch thn 75 Bng 3.18 S lng thuc cn quang s dng can thip 76 Bng 3.19 T l thnh cụng v gii phu v th thut .76 Bng 3.20 Cỏc bin chng sm sau can thip 77 Bng 3.21 Thay i ch s huyt ỏp v s thuc h huyt ỏp sau can thip 79 Bng 3.22 Thay i huyt ỏp theo mc huyt ỏp trc can thip 80 Bng 3.23 Liờn quan gia tui, gii v t l ci thin huyt ỏp 82 Bng 3.24 Liờn quan gia cỏc thụng s huyt ỏp trc can thip v t l ci thin huyt ỏp 82 Bng 3.25 Mi liờn quan gia bờn hp MT, T v protein niu vi t l ci thin huyt ỏp 83 Bng 3.26 Mi liờn quan gia nng creatinin mỏu, MLCT, ch s RRI vi t l ci thin huyt ỏp 84 Bng 3.27 Mi liờn quan gia nng NT ProBNP mỏu vi t l ci thin huyt ỏp 84 Bng 3.28 S thay i ch s creatinin sau can thip 85 Bng 3.29 T l thay i creatinin sau thỏng 85 Bng 3.30 Liờn quan gia tui v gii vi thay i nng creatinin mỏu 86 Bng 3.31 Liờn quan gia T, protein niu v bờn hp ng mch thn vi thay i nng creatinin mỏu 86 Bng 3.32 Liờn quan gia nng creatinin mỏu, MLCT 87 v ch s RRI vi thay i nng creatinin mỏu .87 Bng 3.33 Liờn quan gia ch s huyt ỏp .88 vi thay i nng creatinin mỏu 88 Bng 3.34 Liờn quan gia nng NT ProBNP mỏu vi thay i nng creatinin mỏu .88 Bng 3.35 Cỏc yu t liờn quan ti tỏi hp stent ng mch thn .90 Bng 4.1 Tỏi hp stent ng mch thn/siờu õm Doppler ca cỏc tỏc gi 122 DANH MC HèNH Trang Hỡnh 1.1 Hp l vo ng mch thn trỏi x va Hỡnh 1.2 Hỡnh nh hp ng mch thn lon sn x c Hỡnh 1.3 Hỡnh nh x hỡnh thn .13 Hỡnh 1.4 Hỡnh nh ng mch thn phi v trỏi trờn siờu õm Doppler 14 Hỡnh 1.5 o tc nh trờn siờu õm Doppler ng mch thn 16 Hỡnh 1.6 Hỡnh nh chp ct lp a dóy ng mch thn 17 Hỡnh 1.7 Hỡnh nh hp ng mch thn lon sn x c trờn phim cng hng t 18 Hỡnh 1.8 Hỡnh nh hp ng mch thn x va trờn CHT .19 Hỡnh 1.9 Chp khụng chn lc ng mch thn trc v sau t stent 20 Hỡnh 1.10 Gúc xut phỏt ca ng mch thn 20 Hỡnh 1.11 Phu thut búc mng x va ng mch thn 24 Hỡnh 1.12 Bc cu ng mch thn t on ng mch ch nhõn to 25 Hỡnh 1.13 t stent ng mch thn vi dng c bo v huyt 27 Hỡnh 2.1 Mỏy DSA v phũng can thip mch 37 Hỡnh 2.2 Dng c s dng chp v can thip ng mch thn 38 Hỡnh 2.3 ng vo ng mch ựi v ng mch cỏnh tay .43 Hỡnh 2.4 Gúc chp ng mch thn thng qui nghiờng trỏi 20 44 Hỡnh 2.5 ỏnh giỏ mc hp ng mch thn .45 Hỡnh 2.6 Chn ng thụng can thip phự hp vi cong ng mch ch 45 Hỡnh 2.7 Can thip hp ng mch thn phi bng No - touch technique 46 Hỡnh 2.8 Can thip ng mch thn bng Telescoping technique .47 Hỡnh 2.9 Can thip ng mch thn bng Kissing balloon technique 48 Hỡnh 2.10 K thut can thip ng mch thn qua ng ng mch ựi .50 Hỡnh 3.1 Hỡnh nh siờu õm Doppler ng mch thn trỏi .69 Hỡnh 3.2 Hỡnh nh hp nng, ng tõm ti l vo ng mch thn trỏi 70 106 Ruchin P E., Baron D W., Wilson S H., et al (2007), "Long-term follow-up of renal artery stenting 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36 H v tờn Nguyen Minh L Hoang Thi Th Nguyen Q Ho Thi Kim H Tieu Ngoc D Le Thi M Bui Minh D Chu Thi Ph Khuat Dinh D Nguyen Thanh H Phung Tien Th Tong Phu L Bui Huu C Nguyen Ngoc H Do Thi L Pham Thi Y Hoang Van B Hoang Van D Khuc Van V Nguyen Thi Minh Th Le Van Y Vu Van B Phung Tien Th Tran Thi D Thai Thi H Vu Van Th Nguyen Thi D Nguyen Van Th La Thi Th Nguyen T Nguyen Kim Gi Pham Thi Ng Nguyen Xuan T Nguyen Thi Hoang O Nguyen Thi C Bui Manh T Tui 67 70 76 60 80 75 68 75 71 43 56 72 74 49 65 60 66 50 60 66 63 50 56 84 66 45 62 80 50 83 74 74 65 41 57 52 Ngy vo vin Ngy vin 10.09.12 12.09.12 13.12.12 16.12.12 15.03.12 28.03.12 02.10.12 18.10.12 13.08.12 24.08.12 30.07.12 10.08.12 26.07.12 01.08.12 16.07.12 06.08.12 22.01.13 29.01.13 22.02.13 27.02.13 20.05.13 23.05.13 15.07.13 16.07.13 12.04.13 16.04.13 25.01.13 01.02.13 15.03.13 27.03.13 14.03.13 19.03.13 28.02.13 28.03.13 18.04.13 26.04.13 03.04.13 10.04.13 05.06.13 12.06.13 03.04.13 08.04.13 10.06.13 12.06.13 25.06.13 27.06.13 31.07.13 08.08.13 06.08.13 08.08.13 07.08.13 13.08.13 22.10.13 28.10.13 12.03.14 15.03.14 15.12.14 17.12.14 27.10.14 02.11.14 22.10.14 24.11.14 15.12.14 18.12.14 22.12.14 23.12.14 18.08.14 22.08.14 28.12.14 31.12.14 01.10.14 20.10.14 Mó lu tr I10/1036 I10/1521 I20/348 I21/1471 I07/2 I21/1167 I10/1111 I13/19 I10/122 I10/207 I10/627 I10/1005 Z95/458 I13/9 I21/510 I10/435 I74/56 I10/427 I20/483 I21/1033 I10/363 I21/930 I10/854 I10/921 I10/1060 I10/1472 I10/1362 I10/402 I10/76 I20/2292 I12/23 I71/122 I21/1515 I10/1491 I74/360 I10/1970 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 Do Thi V Nguyen Van U Nguyen Nhat Ph Nguyen Thi O Quach Van Ng Nguyen Vu Ngoc D Nguyen Thi Th Dang Xuan H Nguyen Thi H Le H Nguyen Viet T Nguyen Ch Truong Thi T Nguyen Tho Ch Le Viet C Vu Thi Ng Nguyen Ngoc D Nguyen Thi Tuyet L Nguyen Trong Ng Ngo Huu C Kieu Thi Nh Dinh Thi S Nguyen Van H Nguyen Viet T Nguyen Nhat Ph Ho Thi L Phan Thi Minh Ch 82 58 71 72 75 49 74 51 66 82 70 76 57 69 74 74 71 74 71 54 71 64 51 71 72 81 70 23.07.14 06.08.14 10.12.14 24.12.14 02.07.14 27.11.14 26.06.14 27.11.14 16.04.14 18.03.14 18.11.14 09.12.14 01.04.15 03.02.15 06.03.15 20.04.15 13.04.15 11.03.15 11.03.15 07.04.15 27.03.15 23.01.15 29.01.15 26.01.15 27.01.15 19.01.15 11.05.15 08.08.14 13.08.14 16.12.14 31.12.14 21.07.14 22.12.14 04.07.14 09.12.14 18.04.14 24.03.14 24.11.14 17.12.14 08.04.15 06.02.15 13.03.15 24.04.15 17.04.15 25.03.15 13.03.15 09.04.15 14.04.15 29.01.15 03.02.15 27.01.15 29.01.15 09.02.15 13.05.15 I10/1519 I20/1778 I10/1871 I74/363 I10/1415 I21/1414 I77/3 I10/1962 I10/546 I10/477 I10/1850 I10/2011 G81/144 I10/247 I21/249 I20/713 I20/950 I10/554 I10/524 I10/313 I10/675 I10/46 I10/442 I10/138 I74/87 I20/731 I10/925 H Ni, ngy thỏng 12 nm 2016 XC NHN CA T LU TR H S PHềNG KHT H BNH VINBCH MAI BNH N NGHIấN CU I HNH CHNH H v tờn:Gii: Tui: a ch:Mó bnh ỏn: Ngy vo vin:Ngy vin: II Lí DO NHP VI N THA khỏng tr: Kim soỏt huyt ỏp khú khn bnh nhõn huyt ỏp ang n nh: Phự phi cp: Suy thn tin trin sau s dng thuc UCMC hoc AT1: Tng ure, creatinin khụng gii thớch c nguyờn nhõn: Thn teo nh: Phỡnh ng mch ch bng: au tht ngch khụng tng ng vi mc hp MV: Bnh ng mch chi di: Bnh thõn MV: Lý khỏc III TI N S Tng huyt ỏp: Khụng cú Thi gian: Nm ỏi thỏo ng: Khụng cú Thi gian: Nm Ri lon lipid mỏu : Khụng cú Hỳt thuc lỏ: Khụng cú Thi gian: Nm Tai bin mch mỏu nóo: Khụng Nhi mỏu c tim: Khụng cú cú Thi gian: Nm Thi gian: Nm (Lu ý: < thỏng = 0,5 nm) IV LM SNG au u: Khụng cú au ngc: Khụng cú ỏnh trng ngc: Khụng cú au cỏch hi: Khụng cú Thi MT: Khụng cú Tnh mch c ni: Khụng cú Gan to: Khụng cú Di b sn: cm Nhp tim: ck/ph Nhp tim u: Khụng NYHA: Chiu cao: .cm Cõn nng: .kg Thi gian Trc can thip Sau can thip Sau thỏng Sau thỏng cú HATT (mmHg) HATTr (mmHg) V XẫT NGHI M Sinh húa mỏu Thụng s Kt qu Trc can thip 24h sau thỏng Creatinin Ure Glucose Cholesterol HDL LDL Triglycerid GOT GPT Na+ K+ ClNT - ProBNP Cụng thc mỏu S lng hng cu: G/L S lng bch cu : G/L S lng tiu cu : G/L Tng phõn tớch nc tiu Protein niu: m tớnh Dng tớnh g/L thỏng SIấU M DOPPLER THN Khụng cú Trc can thip Thụng s Bờn phi Bờn trỏi Vp (cm/s) Vd (cm/s) RRI Khụng ph Khụng cú Khụng cú Teo thn Khụng cú Khụng cú Khụng cú Sau can thip (6 thỏng) Thụng s Bờn phi Bờn trỏi Vp (cm/s) Vd (cm/s) RRI Tỏi hp Khụng cú MSCT NG MCH THN Khụng cú M thn hp Bờn phi Mc : % Bờn trỏi Mc : % C hai bờn Mc : % (phi)% (trỏi) V trớ: L vo Thõn c im: ng tõm Lch tõm Xon Chia nhỏnh Khỏc DSA NG MCH THN Bờn MT hp Bờn phi Mc : % Bờn trỏi Mc : % C hai bờn Mc : % (phi)% (trỏi) V trớ: L vo Thõn c im: ng tõm Lch tõm Xon Chia nhỏnh Khỏc Thụng s Trc can thip (mm) Sau can thip (mm) ng kớnh hp nht ng kớnh tham chiu Chiu di tn thng Gúc MT Hp tn d CAN THI P NG MCH THN Lý can thip: Kim soỏt huyt ỏp Bo tn chc nng thn Suy tim Phự phi cp au tht ngc Khỏc: ng mch can thip: Phi V trớ can thip: L vo Trỏi C hai bờn Thõn ng vo: ng mch ựi phi trỏi ng mch quay phi trỏi Dõy dn can thip: 0.014 0.018 Búng nong: Kớch thc mm S lng.cỏi p lc nong: atm Stent: Kớch thc:.mm p lc lờn búng:atm K thut: Nong búng n thun Stent trc tip Nong búng + Stent S lng cn quang:ml Thi gian thc hin th thut:.phỳt Thi gian chiu tia:.phỳt ỏnh giỏ kt qu: Thnh cụng v k thut: Khụng cú Thnh cụng v lõm sng: Khụng cú Tht bi: Khụng a stent cú Nguyờn nhõn tht bi: Nong búng a wire Khỏc Bin chng: T vong Tỏch ng mch ch T mỏu ti v trớ ng vo huyt cn truyn mỏu Tỏch MT Suy thn cp ng kớnhcm Xut huyt n bng S lngn v au hụng lng Xut Bin chng khỏc: T VO NG TRONG THI GIAN THEO DếI Khụng cú Thi im: thỏng Nguyờn nhõn t vong: THUC HUYT P S DNG Trc can thip thỏng thỏng H Ni, ngy thỏng nm NGI NHP D LIU VO BNH N MU Lờ Vn Cng ... Y DC LM SNG 108 Lấ VN CNG NGHIÊN CứU ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG Và KếT QUả ĐIềU TRị Bệnh nhân tăng huyết áp có HẹP Động mạch thận Bằng phương pháp can thiệp qua da Chuyờn ngnh: Ni tim mch... phng phỏp can thip qua da vi mc tiờu: Kho sỏt c im lõm sng, cn lõm sng v c im tn thng v hỡnh thỏi hc ng mch thn bnh nhõn tng huyt ỏp cú hp ng mch thn c ch nh can thip qua da ỏnh giỏ kt qu can thip... 99 4.3 Kt qu can thip ng mch thn qua da 102 4.3.1 V k thut can thip ng mch thn 102 4.3.2 Kt qu sm sau can thip ng mch thn 105 4.3.3 Kt qu theo dừi dc sau can thip ng mch thn