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MC LC

I. BNH NG MCH VNH .................................................................................... 1


1.1 Tng quan........................................................................................................... 1
1.2 Cha tr .............................................................................................................. 2
1.3 Bnh mch vnh bnh nhn tiu ng ........................................................... 2
1.4 Bnh mch vnh ph n .................................................................................. 2
1.5 Bnh mch vnh ngi cao tui ....................................................................... 4
II. TNG QUAN V BNG NONG MCH ............................................................... 5
2.1 S lc lch s v bng nong mch (balloon catheter) ........................................ 5
2.2 Phn loi............................................................................................................. 5
2.2.1 Bng p lc cao (bng cng) ........................................................................ 5
2.2.2 Bng p sut thp (bng mm) ..................................................................... 6
2.3 Vt liu bng ...................................................................................................... 7
2.4 Cng dng .......................................................................................................... 8
2.4.1 Gin n ......................................................................................................... 8
2.4.2 Phn phi stent (Stent delivery) .................................................................... 8
2.4.3 Phn phi thuc (Drug delivery) ................................................................... 9
III. MI QUAN H GIA BNH TIU NG V NG MCH VNH ....... 11
3.1 Tng quan......................................................................................................... 11
3.2 Phng php iu tr bnh MV bnh nhn tiu ng ................................ 12
3.2.1 Th thut bc cu........................................................................................ 13
3.2.2 Nong mch vnh v t stent ...................................................................... 13
IV. NG MCH VNH PHN NHNH ................................................................ 16
4.1 Gii thiu ......................................................................................................... 16

4.2 Phn loi........................................................................................................... 16


4.3 Stent n v stent i........................................................................................ 17
4.3.1 Phng php t mt stent.......................................................................... 18
4.3.2 Phng php t hai stent ........................................................................... 18
4.4 Kissing balloon ................................................................................................. 20
V. NGHIN CU QUY TRNH NH GI P SUT N NH MC CA
BNG CA STENT THNG.................................................................................. 22
5.1 Dng c, thit b ............................................................................................... 22
5.2 Quy trnh thc hin ........................................................................................... 23
5.3 Kt qu v tho lun ......................................................................................... 24
VI. KT LUN ............................................................................................................ 27
TI LIU THAM KHO ........................................................................................... 28

DANH MC HNH
Hnh 1: Cc cn bnh chnh gy t l t vong cao nht trn th gii vo nm 2011 (trong
bnh hp ng mch vnh dn u) ............................................................................ 1
Hnh 2: T l mc bnh ng mch vnh nam gii v n gii t nm 1997 n 2009 ... 3
Hnh 3: Bng nong vnh ng mch ................................................................................ 5
Hnh 4: Bng nong p lc cao (non-compliance) ............................................................. 6
Hnh 5: Bng p lc thp (compliance) ........................................................................... 6
Hnh 6: Cng thc phn t ca polyvinyl chloride (PVC) ................................................ 7
Hnh 7: Qu trnh to vt liu polymer ............................................................................ 7
Hnh 8: Bng vi thit k m hnh xng ch................................................................... 9
Hnh 9: Bng c mng a ng thuc - thuc thot ra ngoi mng bng ....................... 10
Hnh 10: Qu trnh gy tn thng mch mu bnh tiu ng .................................. 11
Hnh 11: So snh nguy c nhi mu c tim v cht ca cc loi stent( tin cy 95%). . 14
Hnh 12: So snh kh nng hnh thnh huyt khi ca cc loi stent ( tin cy 95%)... 15
Hnh 13: Kiu phn loi vng ng mch phn nhnh Lefevre ...................................... 16
Hnh 14: Kiu phn loi vng ng mch phn nhnh Medina ...................................... 17
Hnh 15: Phng php t mt stent.............................................................................. 18
Hnh 16: Cc phng php t hai stent ........................................................................ 19
Hnh 17: Phng php t stent th hai thng qua thanh chng stent th nht ............. 20
Hnh 18: Phng php m rng vng tt nghn v tr mch phn nhnh bng kissing
balloon. .......................................................................................................................... 20
Hnh 19: Kissing balloon trong trng hp dng hai stent ............................................ 21
Hnh 20: Bn nc (c th kim sot c nhit )...................................................... 23
Hnh 21: Bng v khi vt qua p sut n nh mc ...................................................... 24
Hnh 22: M hnh kim tra p sut n nh mc ca bng ............................................. 24

Hnh 23: Chiu di bng thay i khi thay i p sut (a) v chiu di thay i ph thuc
vo mi loi stent (b) ..................................................................................................... 26

DANH MC BNG
Bng 1: Bng so snh cc vt liu lm bng. ................................................................... 8
Bng 2: Bng so snh t l to huyt khi sau khi t mt stent v hai stent ng mch
chnh v nhnh (sau 6 thng) ......................................................................................... 18
Bng 3: Bng kt qu o p sut n nh mc 10 bng stent trn .................................. 24
Bng 4: Kt qu o p sut n nh mc ca bng lm t vt liu khng tng thch .... 25

I. BNH NG MCH VNH


1.1 Tng quan
Bnh ng mch vnh (MV) gy nn bi nhng mng bm c hnh thnh t
m, cholesterol v cc cht khc trn thnh ng mch vnh. Lu dn, cc mng bm ny
ln ln v lm hp dng chy ca mu, ng thi lm gim lng mu cha cht oxy dn
v tim. Hin nay trn ton th gii c khong 40 triu ngi mc bnh ng mch vnh
(MV). Mi nm c thm khong 5,8 triu ngi mc BMV. BMV l nguyn nhn gy
t vong hng u trong cc bnh tim mch. Ring nm 2001 c 7,2 triu ngi cht v
BMV. Ti Vit nam BMV ang tng ln mt cch r rt. Theo cc s liu thng k th t
trc nm 1963 BMV l rt him gp, sau nm 1963 BMV bt u gia tng. Ring ti
TP H Ch Minh trong nm 2000 c 3222 bnh nhn mc bnh v t vong 122
trng hp.
Nu cc mng bm ny khng n nh, b v nt, mu s ng cc li ti nhng
ch v nt trn cc mng bm , khin mu khng th lu thng, v hu qu l dn n
chng nhi mu c tim. Khi ln tui, c bit nam gii trn 45 tui v n trn 55 tui th
nguy c mc bnh MV rt cao. Nguy c ny cng xy ra trong gia nh c ngi mc
bnh tim sm, c th l c cha hoc anh ch em b bnh tim trc 55 tui hay c m hoc
ch em gi b bnh trc 65 tui.

Hnh 1: Cc cn bnh chnh gy t l t vong cao nht trn th gii vo nm 2011 (trong
bnh hp ng mch vnh dn u)
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Mt iu ng lo ngi l bnh MV v nhi mu c tim xut hin ngy cng


nhiu nhng ngi di 50 tui, c c nhng bnh nhn di 40 tui. Cng nh trn
th gii, ti Vit Nam bnh mch vnh ang tr thnh mi nguy ln cho sc khe cng
ng v l gnh nng khng ch cho ngi bnh.
1.2 Cha tr
Bnh MV l cn bnh eo ui ngi bnh sut i v thng khng
c pht hin sm, n khi triu chng xut hin th bnh tin trin kh lu. Do vy,
cch phng bnh tt nht l phi tm sot cc yu t nguy c, kim sot chng ng thi
pht hin bnh sm v iu tr kp thi. Trong trng hp cc phng php iu tr bnh
MV nh: thay i li sng, dng thuc thch hp, nong hoc t gi MV u b
tc th m bc cu MV s l cu cnh gip bnh nhn thot khi cn bnh him ngho
ny. Phu thut bc cu MV l bin php s dng cc mch mu khe mnh t chn,
ngc, bng lm cu ni gip mu lu thng n nui vng c tim sau v tr tc nghn.
Tuy nhin, phu thut bc cu MV ch mang li hiu qu cao nht nu thc hin ng
thi im. Nu khng pht hin sm v phu thut kp thi th nhiu vng c tim b tn
thng khng hi phc v hiu qu phu thut cng gim i. Do vy, vic tm sot
pht hin v iu tr sm bnh MV l v cng quan trng.
1.3 Bnh mch vnh bnh nhn tiu ng
Qua rt nhiu nghin cu ti nhiu trung tm khc nhau ngi ta nhn thy rng
nguy c b BMV bnh nhn tiu ng tng gp 2-4 ln so vi ngi khng b tiu
ng. Trong khi t l trong dn c ni chung l 2-4 % th t l ny bnh nhn tiu
ng tng ln mt cch ng k ti 55%. T l t vong do cc bnh tim mch ni chung
ngi bnh tiu ng cng cao gp 2-6 ln so vi ngi khng b bnh.
1.4 Bnh mch vnh ph n
T l ph n mc bnh ng mch vnh tng t 2-3 ln sau thi k mn kinh. S
gia tng ny hon ton khng gii thch c nguyn nhn, nhng lng cholesterol,
chng cao huyt p v lng cht bo ng xung quanh vng bng nhiu trong giai on
ny c nh gi l nhng nguy c lm pht sinh bnh nghn ng mch vnh ph
n.
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Nhng cuc nghin cu y hc v bnh tim mch trc y thng tp trung vo


n ng. Nhng gi y, cc nh khoa hc nhn ra rng c s khc bit r nt v bnh
ng mch vnh gia n ng v ph n. Chng hn, nhng ngi n ng b nhi mu
c tim thng c nhng biu hin c th nh: cn au tht ngc, khi u t ngc v
lan ra vai, c, cnh tay. ph n cng c nhng triu chng tng t, nhng cn thm
nhng du hiu ph khc nh: kh th, nng, nn ma, au hm, au lng v cm gic
mt mi. Chng nhi mu c tim ph n thng xy ra khi h lo lng hoc b cng
thng thn kinh, ngay c lc ng. Trong khi n ng, nhi mu c tim thng xy ra
khi luyn tp th dc hay trong lc ang lm vic. Do ph n khng thng xuyn c
nhng biu hin nhi mu c tim c th, nn thng chm tr trong vic iu tr v i
din vi nguy c t vong nhiu hn n ng.

Hnh 2: T l mc bnh ng mch vnh nam gii v n gii t nm 1997 n 2009


Hip hi tim M c nhng hng dn c bit gip ngn nga v iu tr ng
mch vnh ph n. Nhng hng dn ny cp n s thay i li sng, s dng
thuc men v iu tr hooc-mon ph n trong giai on mn kinh. Di y l nhng
thay i v li sng gip ngn nga bnh ng mch vnh.
- Khng nn ht thuc v trnh ht th khi thuc th ng.
- Thng xuyn luyn tp nhng bi tp vi cng va phi, khong 30 pht
/ngy nh i nhanh. Vic ny s hu ch hn cho bn nu c thc hin vo tt c cc
ngy trong tun.

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- n nhng thc phm c li cho tim, hn ch cc thc phm c bo v lng


cholesterol cao.
- Duy tr ch s trng lng c th v s o vng eo di 88cm.
- Trong trng hp bn c nhng tru chng ca bnh ng mch vnh, cn
trnh lo lng v mun phin.
- Khng nn ung ru.
- Trnh nhng thc phm lm tng huyt p, gim ngay vic n mn nu bn nag
b chng huyt p cao.
1.5 Bnh mch vnh ngi cao tui
Tui cao cng vi nhng thay i trong i sng kinh t, x hi nh hng
nhiu ti tp qun sinh hot ca ngi Vit Nam v c th l mt nguyn nhn quan
trng ca t l gia tng bnh MV nc ta. Hin nay c khong 9% bnh nhn ni tr
ti Vin Tim mch Vit Nam. Bnh vin Bch Mai c s ca mc bnh MV a s l
ngi cao tui.

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II. TNG QUAN V BNG NONG MCH


2.1 S lc lch s v bng nong mch (balloon catheter)
Pht trin t nhng nm 1970, bng p sut cao (high-pressure balloons) c s
dng trong th thut m rng mch mu. Thng thng s dng dung dch chn sng
hoc dung dch ng trng (thng qua ng tim) nh p sut cao p mng bm vo
thnh mch v cho php dng mu hot ng bnh thng. Thu hi bng bng cch bm
chn khng cch ny cho php bng co rt li. Phng php ny c u im l t lm
vnh mch b tn thng. Hin nay, bng p sut cao c thnh mng, nh, rt ph hp
cho nhng ng mch nh vi ng knh, chiu di v hnh dng c vng phn b rng,
c bit l nhng thit k chuyn bit c hnh dng phc tp dng cho nhng ng dng
ring hay dng ph. Bng c ci thin vi thit k tng tnh linh hot ph hp cho
nhiu thit b y khoa. C nhiu ng dng nh: thit b phn gii thuc, thit b a stent,
nong mch vnh

Hnh 3: Bng nong vnh ng mch


2.2 Phn loi
C hai loi bng cn bn dng trong y khoa. Mt l bng c p sut cao, hai l
loi p sut thp. Hai loi ny c mt s c im chung.
2.2.1 Bng p lc cao (bng cng)
L loi bng khng n hi, gin n nh lc nn. Thng c lm t vt liu
khng p ng hoc t p ng (non-compliant/low-compliant material) - l vt liu gip
cho bng lu gi c hnh dng v thit k ngay khi di p sut cao. Thnh bng
loi ny mng v c bn cng gin cao. Bng cng c ng knh t 0.5-50 mm hoc

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hn v c th c bt k chiu di no m vn gi c thnh mng. C th thit k bng


vi nhiu ng knh khc nhau v c u nhn t 1-90 .

Hnh 4: Bng nong p lc cao (non-compliance)


2.2.2 Bng p sut thp (bng mm)
L loi bng n hi, thng lm t silicone hoc nha, dng ng, c s dng
c nh, loi bng mm ny khng th gi c ng hnh dng khi p sut cao.

Hnh 5: Bng p lc thp (compliance)


Bng phi kim sot c kch thc v p sut m bo rng n s khng tip
tc gin n v lm v ng mch sau khi phong ta c tc nghn. Balloon compliance
l cm t m t trng thi ng knh ca bng thay i ph hp vi p sut. i vi
bng cng, n c th gin khong 5-10% vi p sut nh mc trong khi loi bng mm
c th co gin 100-600%. Sau khi gim p sut, bng mm tr li hnh dng v kch
thc ban u. Loi ny thng khng th s dng cho nhng ng dng y khoa c p
sut cao.
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2.3 Vt liu bng


Loi bng u tin c ch to t polyvinyl chloride (PVC), c thnh dy cng
ging nh cc loi bng mm ngy nay. T u nhng nm 80, crosslinked polyethelene
v polyester (PET) polyethylen terephthalate c chp nhn l vt liu cho bng, v
chng dn thay th PVC.

Hnh 6: Cng thc phn t ca polyvinyl chloride (PVC)


Cui nhng nm 80, vt liu nylon ra i v polyerethane c sn xut ngay sau
. Nylon khng bn nh PET nhng li l vt liu y ha hn v n mm hn. Ngy
nay, hu ht cc loi bng mm u s dng vt liu nylon v PET. PET c u im l c
bn co gin tt, chu c p sut nh mc cao trong khi nylon th mm hn. Mt
tnh cht u vit na l kh nng truyn nhit v r v mt quang hc, chnh iu ny
lm cho bng PET ph hp vi cc tia laser, nng lng siu m v sng ngn. Mt c
im vt tri ca PET l kh nng c thnh thng mng v hnh dng rt chnh xc,
PET c thnh cc k mng, dao ng khong 5-50m.

Hnh 7: Qu trnh to vt liu polymer


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Bng bng t nylon th mm hn so vi lm bng PET, mc d khng bn bng,


chnh v vy bng nylon cn phi c thnh dy hn. Tuy nhin, chnh v mm nn n d
dng gp li v rt ra khi ng thng.
Bng 1: Bng so snh cc vt liu lm bng.

2.4 Cng dng


2.4.1 Gin n
Bng gin n m vng ng mch b tt nghn (c dng trong phng php
can thip to mch qua da PTCA). Cc bng thng dng trong trng hp ny thng
c ng knh khong 2-4mm, chiu di 10-40mm v p sut nh mc khong 10-20
atm.
2.4.2 Phn phi stent (Stent delivery)
Bng cng thng c s dng t v lm gin n stent, nhm lm gim t l
ti hp v ng kn thnh ng mch. Stent, bng bc quanh ng thng v c a vo
v tr tt nghn. Bng gin n lm stent gin theo, do lm thnh mch cng m ra.
Dng p sut gin n cho php stent gin n y trc khi tng tc vi thnh
ng mch. S dng bng cng (vt liu t tng thch) gip cho stent v ng mch
khng b gin qu mc, m bo tnh an ton. Sau khi lm xp, bng c a ra khi c
th trong khi stent vn cn li.

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2.4.3 Phn phi thuc (Drug delivery)


Bng cng (high-pressure balloon) rt hu ch khi dng trong phn phi thuc ti
cc v tr c bit trong c th. Mt phng php s dng bng a thuc vo v tr
tn thng hoc tc nghn l s dng 2 bng ring l trn thn ng thng phong
ta vng h tn, trong khi thuc s truyn qua khe l gia 2 bng thot ra ngoi. Khi qu
trnh thao tc thc hin xong, thuc chy ra ngoi, vng tn thng c m rng, sau
lm xp bng v co rt li.

Hnh 8: Bng vi thit k m hnh xng ch


Mt loi bng hnh dng xng ch (dog bone-shaped balloon) c th phn phi
thuc bng cch s dng phng php tng t. on cui ca bng c th bng hoc
khc ty thuc vo hnh dng mch. Khi bm bng, u cui s phong ta vt thng v
thuc thot ra ngoi thng qua cc l on gia bng. C th dng tia laser, ng thng
nng hoc cc thit b khoan to b mt l.
Mt loi bng PET thnh cc mng c th bin i thnh lp mng c nhiu ht
porous, vi ng knh mt vi m. Mt bng c th c ti hng nghn l. y l
phng php phn gii thuc c hiu qu to ln v c th kim sot ng kch thc l,
do c th iu kin ng lng thuc mc d rt nh ti v tr tn thng. t bit c
ngha i vi cc loi thuc c hay t tin . Mc d bng loi ny c nhiu vi ht
nhng cc k bn.

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Hnh 9: Bng c mng a ng thuc - thuc thot ra ngoi mng bng


Thuc ph trn b mt bng v c phng thch ti v tr ch trong c th. Qu
trnh vn chuyn thuc c thc hin nh p sut, tia laser, nhit

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III. MI QUAN H GIA BNH TIU NG V NG MCH


VNH
3.1 Tng quan
Danh t tiu ng hay diabetes mellitus l tn gi chung ca mt nhm bnh
nh hng n vic s dng glucose, mt loi ng trong mu hay ng huyt. L mt
nhm bnh ri lon chuyn ha cachohydrat khi hoocmon insulin ca ty b thiu hay
gim tc ng trong c th, biu hin bng mc ng trong mu lun cao.
Bnh tiu ng c th gy ra bin chng trn nhiu c quan, nhng thng gp,
gy tn km v nghim trng hn ht l bin chng tim mch. V cc c quan v b phn
trong c th u cha nhiu mch mu, cho nn tn thng mch mu s dn n tn
thng cc c quan nh mt, thn, thn kinhC s lin quan cht ch gia bnh tiu
ng v bnh tim mch. Tn sut bnh tim mch ngi b tiu ng cao gp 2-4 ln
sao vi ngi khng b. Khong 2/3 s bnh nhn tiu ng t vong l do bin chng
tim mch nh nhi mu c tim v t qu.

Hnh 10: Qu trnh gy tn thng mch mu bnh tiu ng


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C nhiu nguyn nhn gii thch ti sao bnh tim mch thng gp ngi b tiu
ng. ngi b tiu ng, lng ng huyt trong mu tng cao lm tn hi n
cc mch mu, mch mu cng nh th cng d b tn thng hn. Lng ng trong
mu cao lm tng lng ng m thnh mch v lm chm dng chy ca mu. Theo
thi gian, s lng ng m c th pht trin thnh mng x va v lm dy thnh mch
mu. Nhng mng bm thnh mch c th v ra, tri dt n ni khc v lm tc
nghn. Ti ch v, cc t bo ca h min dch bt u hot ng, qu trnh ng mu
xut hin to cc mu ng, gy cn tr lu thng mu hoc tc mch t ngt.
Tn thng mch mu nh: xy ra cc nhnh ca ng mch v cc mch mu
nh hn. Cc mch mu nh b nh hng bi bnh tiu ng c th lm suy yu thnh
mch v lm cho chng phnh ln nh qu bng gi l vi phnh mch. Thnh ca nhng
mch mu ny sau b r r, gy ra tc nghn dng chy, lm gim cung cp oxy v
cht dinh dng n cc m do mch mu ny chi phi, c th dn n tn thng hoc
cht m. Tnh trng ny cng l yu t gp phn quan trng trong cc bin chng kinh
in ca bnh tiu ng nh: bnh vng mc, bnh thn v thn kinh do tiu ng.
3.2 Phng php iu tr bnh MV bnh nhn tiu ng
Khi bnh nhn tiu ng mc cc bnh lin quan n ng mch vnh, cn phi
tin hnh ti thng mch mu. Thut ng ti thng mch mu n gin ngha l hi phc
li dng mu t tim n cc b phn khc ca c th sau khi mch mu b vn cc do
mng bm. Trong trng hp lin quan n tim mch, c th thc hin th thut phu
thut bc cu, nong mch vnh v t stent.
Nong mch vnh v t stent thng c gi chung l PCI (percutaneous
coronary intervention). Cn nhiu tranh ci xoay quanh vn chn PCI hay bc cu
ng mch cho bnh nhn tiu ng. n gin bi v cha c nghin cu lm sng no
tp trung su vo vn lm sao x l cc ng mch nh i vi bnh nhn tiu ng.
Hn th na, cc bnh ng mch vnh ngi tiu ng thng khc v c tnh trng
xu hn. V d, nhng bnh nhn b tiu ng thng c mng x va phn b nhiu
hn, di hn v nh hng n nhiu ng mch, ch khng n gin ch l mt v tr tc
nghn nh nhng ngi bnh khng b tiu ng. Sau khi thc hin th thut PCI,
nhiu bnh nhn tiu ng xut hin tt nghn tr li do m so tng sinh qu mc (ti
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hp). iu ny gii thch ti sao cc bnh nhn tiu ng cn phi tip tc tin hnh cc
th thut ln na.
3.2.1 Th thut bc cu
Trc y, phu thut bc cu l s la chn hng u cho bnh nhn tiu ng,
bi v cc nghin cu trc cho rng phu thut bc cu em li kh nng sng st lu
di hn so vi PCI. Nhng cc nghin cu hin nay (SCAI Statement on the BARI 2D
Trial v SCAI Statement on the SYNTAX Trail) lm thay i quan nim ny. Ngy
nay nhiu stent ph thuc xut hin trn th trng tiu th, nhiu nh nghin cu tin
tng rng PCI l cch thc tt nht.
Trong khi , theo HealthDay News ngy 15.10.2013, cc nghin cu cho thy t
l ngi cht v t nguy c tn cng tim mch ngi tin hnh th thut bc cu hn
nhng ngi thc hin nong mch vnh. Nong mch vnh ch c nh trong mt thi
gian, trong khi bnh tiu ng c tnh cht lan ta. Khng n gin ch l tn thng
mt mch mu, m h tn ton b mch.
Mt nghin cu c cng b vo 11.5.2012 th cho rng bnh nhn tiu ng
tri qua th thut bc cu loi b vng ng mch b tc nghn th sng lu hn so vi
nhng ngi chn phng php nong vnh ng mch.
3.2.2 Nong mch vnh v t stent
Cho n hin nay, kt qu lm sng khi so snh gia cc loi stent ph thuc vi
nhau v so snh stent ph thuc vi stent trn vn cn gy nhiu tranh ci khi dng cho
bnh nhn tiu ng.
Theo nghin cu ca Sripal Bangalore v cc cng s pht hnh vo 10.8.2012 th
dng stent ph thuc em li hiu qu cao (gim cc ri ro v ti thng mch mu, bao
gm hnh thnh huyt khi tr) hn so vi dng stent trn khng ph thuc. Bn cnh
, cn c s khc bit ng k khi s dng stent ph cc loi thuc khc nhau. Stent ph
everolimus th em li hiu qu cao nht (xc sut 87%), sau n stent ph sirolimus,
paclitaxel, zotarolimus (hnh 9, hnh 10).

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Hnh 11: So snh nguy c nhi mu c tim v cht ca cc loi stent( tin cy 95%).

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Hnh 12: So snh kh nng hnh thnh huyt khi ca cc loi stent ( tin cy 95%).
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IV. NG MCH VNH PHN NHNH


4.1 Gii thiu
Tn thng ng mch vnh phn nhnh chim khong 15-20% trong tng s
bnh ng mch vnh. Tc nghn vng phn nhnh l mt trong nhng tn thng phc
tp v gy kh khn khi tin hnh tr liu bi v cn phi hi phc c khong trong ca
ng mch chnh ln ng mch nhnh. Mc tiu ca liu php iu tr l phi ti u kt
qu th thut v quan trng hn l phi t thnh cng v mt lu di nh l t l ti hp
tr thp v t gp cc vn bt li ln trong lm sng. Phng php nong mch vnh
phn nhnh bng bng em li t l ti hp cao. Mc d stent thng em li kt qu y
ha hn nhng m t l ti hp vn cn cao. Phng php s dng stent ph thuc lm
thay i cch thc tr liu kiu tn thng phn nhnh ny, tuy nhin vng ng mch
nhnh b ng li t ngt khi s dng chin lc t mt stent, bn cnh khi s dng
chin lc t hai stent th lm hnh thnh huyt khi v ti hp.
4.2 Phn loi
ng mch vng phn nhnh khc nhau ty vo v tr, ti trng ca mng bm,
gc phn nhnh, ng knh v v tr vng phn nhnh. Do tnh c trng tng vng nh
vy cho nn phi chn chin lc nong vnh ng mch tt nht, ph hp nht cho tng
kiu phn nhnh. Thng thng kiu phn loi vng ng mch phn nhnh b tn
thng ca Lefevre c s dng nht. Tuy nhin, kiu phn loi ny cng vi mt s
phn loi c khc thng gy kh nh.

Hnh 13: Kiu phn loi vng ng mch phn nhnh Lefevre
Trang 16

i vi kiu phn loi Medina th n gin, d nh m cung cp y thng tin


cn thit. Kiu phn loi ny m t bt k on hp no vt qu 50% lng mch trong ba
nhnh theo trnh t sau: ng mch chnh, nhnh xa v nhnh bn. K hiu 1 biu
tng c s hin din ti hp v k hiu 0 c ngha l khng c ti hp.

Hnh 14: Kiu phn loi vng ng mch phn nhnh Medina
Vng tc nghn phn nhnh kiu n gin th v tr tc nghn nm mch chnh
hay mch xa (1,1,0; 1,0,0 v 0,1,0). Liu php cha tr cng n gin hn, thng thng
s dng t mt stent trong phn ng mch chnh, v bao ph lun vng nhnh. Tuy
nhin, trong trng hp vng tc nghn phn nhnh phc tp, nh trong trng hp
1,0,1; 0,1,1 v 1,1,1 (vng tn thng nm phn nhnh) cho nn cn phi s dng thm
mt stent na mi em li hiu qu.
4.3 Stent n v stent i
Khi s dng stent, mt cu hi ln c t ra l c hay khng vic t stent c
hai vng, vng ng mch chnh v vng ng mch nhnh. Dng nh stent i th hiu
qu hn bi v phng thc ny em li kt qu sau khi t tt. Tuy nhin, vn cn nhiu
lo ngi v cc bt li v lu di nh l to huyt khi.

Trang 17

Bng 2: Bng so snh t l to huyt khi sau khi t mt stent v hai stent ng mch
chnh v nhnh (sau 6 thng)
4.3.1 Phng php t mt stent
i vi phng php ny, c th dng hoc khng dng bng nong mch v tr
nhnh bn.

Hnh 15: Phng php t mt stent


4.3.2 Phng php t hai stent
Nhiu k thut t stent vo vng ng mch tn thng phn nhnh c pht
trin (hnh 14). Trong , phng php T-stenting v reverse T-stenting th khng m
bo vng ng mch nhnh c ph stent hon ton. Trong k thut T-stenting, mt
stent ban u c t vo v tr ng mch nhnh, sau stent th hai t vo ng
mch chnh. i vi reverse T-stenting th ngc li, stent ban u c t vo ng
mch chnh, stent th hai s lung qua thanh chng nn ca stent ban u i qua vng
Trang 18

ng mch nhnh. K thut ny c s dng rng ri trong trng hp ng mch ng


mch chnh b tn thng, v stent t ng mch nhnh nhm mc ch ti u ha kt
qu cha tr. Trong trng hp ny, v tr tn thng gn ging hnh ch T, gc gia
ng mch nhnh v ng mch chnh ln hn 70 s lm cho stent nong vng tc
nghn d dng hn. Tc nghn ti hp mch nhnh thng xy ra sau khi t stent, cho
nn kh nng bao ph stent v tr ny l cc k quan trng.

Hnh 16: Cc phng php t hai stent


Ngc li, cc k thut Culotte, Crush v Simultaneous-kissing stent m bo
vng nhnh c stent bao ph hon ton. i vi k thut Culotte, stent u tin c
a vo mch nhnh bng h thng bng v ng thng, sau bng v ng thng a ra
ngoi, stent s t c phn nhnh ln phn mch chnh, sau stent th hai thng qua
thanh chng stent th nht v t mch chnh. Trong phng php Crush, c hai stent
u t cng lc mch nhnh v mch chnh, iu ny s lm san bng cc t bo nh
ln dc trong lng mch chnh. Nhc im ln nht ca cc phng php ny l nhiu
Trang 19

lp kim loi trong lng mch, cho nn d hnh thnh huyt khi. Vi Simultaneouskissing, hai stent s c t vo mch chnh v mch nhnh, k thut ny c thi gian
thc hin ngn hn v t gp cc tr ngi xu hn so vi phng php T-stenting.

Hnh 17: Phng php t stent th hai thng qua thanh chng stent th nht
4.4 Kissing balloon
Kissing balloon (KS) l k thut chuyn dng u tin dng nong mch vng
phn nhnh v vn tip tc ng vai tr quan trng cho n nay. Kissing balloon c hai
nhim v chnh: (1) tin phong m rng v sa cha tn thng lng ng mch v (2)
gin n stent. Tuy nhin, i vi nhng mng bm canxi qu phc tp v nguy him th
khng dng k thut ny. Quyt nh chn kissing balloon cn ph thuc vo nhiu yu
t nh: kiu thit k stent, vt liu bng (tng thch hay khng tng thch), ng knh
bng, v tr tn thng.Thng thng, p sut dng bm bng nm trong khong 814 atm v p sut bm bng mch nhnh nh hn p sut bm bng mch chnh.

Hnh 18: Phng php m rng vng tt nghn v tr mch phn nhnh bng kissing
balloon.
Trang 20

Hnh 19: Kissing balloon trong trng hp dng hai stent


Trong qu trnh t hai stent vo vng mch phn nhnh, s xy ra mt s tip xc
(kiss) nh gia bng-bng, bng-stent, cho nn ngi ta gi phng php dng bng t
stent ny l kissing balloon.

Trang 21

V. NGHIN CU QUY TRNH NH GI P SUT N NH


MC CA BNG CA STENT THNG
Mi loi bng s c bm t ti ng knh danh ngha (nominal) ca ring
tng loi. p sut bng dao ng t p sut danh ngha ti p sut n nh mc. Tt c
cc bng u c th gin trn kch thc danh ngha vi p sut cao hn p sut danh
ngha.
p sut n nh mc l p sut cc i m ti bng khng b v. Trong kim
tra in vitro, 99.9% bng s khng n di hoc ti p sut n nh mc vi tin cy
95%. p sut n nh mc phi c tnh ton v dn nhn. p sut bng khng c
vt qu p sut n nh mc.
H thng bng - ng thng cn phi c kim tra v nh gi cc ch tiu nh p
sut danh ngha v p sut n nh mc m bo an ton v hiu qu trong khi s
dng. Bng phi th hin v hot ng theo ng thit k khi c bm phng ln v
khng xut hin nguy c r r hoc n.
5.1 Dng c, thit b
Thit b dng trong kim tra phi c kh nng kim sot chnh xc v th tch, p
sut, tc chy, gim thiu sai lch khi thc hin lp li. Thit b phi o v v hoc th
hin biu p sut v th tch ca bng nong mch, o lng khong thi gian bm
phng v x hi xp bng.
Cc thit b, dng c gm c:
B nc (c th cha th tch ln ti 3.5l)
My m thi gian
Dung dch bm
My kim tra v tr r r
ng bm hoc l thit b tng ng ( chnh xc 5%, duy tr c p lc
bm, tun th theo tiu chun ISO 594-1 hoc ISO 594-2).

Trang 22

Hnh 20: Bn nc (c th kim sot c nhit )


5.2 Quy trnh thc hin
Quy trnh kim tra bng nong thng c thc hin bng cch s dng kt hp
gia kim tra p sut v kim tra su chn khng xc minh qu trnh bm phng/lm
xp bng, thng tin v ng cong gin n.
Dng phng php Crescent Burst Tester tnh (ISO 10555)
Quy trnh:
a. u tin, lm y b nc bng nc sch, iu chnh nhit nc n
nhit 37OC (gi tr nhit c th sai lch 0.2)
b. Tip theo, cho dung dch bm vo bng bng ng bm (Lu , trong bc
thao tc ny trnh lm h hi bng, nu c lp tc quay li bc a vi bng
khc)
c. Nhn chm ton b bng vo bn nc
d. Gi nguyn bc c t nht trong vng 2 pht
e. Thi phng bng t p sut ban u cho n khi ti p sut m bng n
(ghi nhn li p sut bng v)
f. Tin hnh tng t t bc a n bc e i vi cc bng khc m bo
c ngha v mt thng k
g. Thc hin tnh ton p sut n nh mc ( chnh xc ng tin cy).

Trang 23

Hnh 21: Bng v khi vt qua p sut n nh mc

Hnh 22: M hnh kim tra p sut n nh mc ca bng


5.3 Kt qu v tho lun
Thc hin kim tra p sut n nh mc ca 10 bng stent trn, kt qu thu c
th hin qua bng bn di.
Bng 3: Bng kt qu o p sut n nh mc 10 bng stent trn

H thng bng stent trn MicroDriver


STT
ng knh bng
(mm)

10

2.25 2.25 2.26 2.25 2.25 2.25 2.26 2.25 2.25 2.25

Trang 24

p sut danh nh
(atm)

13

13

12.9

13

12.9

13

13

13

13

p sut n nh
mc (atm)

21

21

21

21

21.1

21

21

21

21

Nhn xt: Ngoi mu bng s 10 khng c kt qu v k thut vin kim tra lm


h bng ngay giai on bm cht lng, 9 mu cn li u cho kt qu o p sut n nh
mc l 21 atm. Nh vy, bng phn phi stent trn u cho p sut n nh mc l nh
nhau v nm trong gii hn thit k.
Ngoi ra, quy trnh kim tra cng tin hnh nh gi p sut n nh mc cc loi
bng c ng knh khc nhau, bng 4 th hin kt qu thu c.
Bng 4: Kt qu o p sut n nh mc ca bng lm t vt liu khng tng thch

ng
knh bng
(mm)

Chiu di bng (mm)


20

30

40

60

80

100

120

150

180

200

3.0
4.0
24 ATM
5.0
22 ATM

6.0
7.0
20 ATM

18 ATM

8.0
9.0

18 ATM

10.0
14 ATM
12.0
Mt vn cn ch l kim tra thng s p sut phi i i vi kim tra chiu
di bng, c bit l khi bng gin n di p sut cao, thay i chiu di bng cng nh
hng n thnh mch, n v tr gn hoc xa vng tn thng cn cha tr.

Trang 25

Hnh 23: Chiu di bng thay i khi thay i p sut (a) v chiu di thay i ph thuc
vo mi loi stent (b)
Nhn xt: Khi thc hin kim tra p sut n nh mc ca cc loi bng c ng
knh t 3mm n 12mm v chiu di t 20mm n 200mm. Kt qu cho thy bng c p
sut n nh mc nm trong gii hn cho php ty thuc vo ng knh v kch thc
ca mi loi bng. Bn cnh c th thy rng bng c ng knh cng ln th p sut
n nh mc cng gim, tuy nhin y v s lng bng kim tra cha ln, cho nn
cn phi tin hnh kim tra vi s lng ln c ngha v mt thng k. Ngoi ra,
mt vn cn c quan tm l bng c cng kch thc nhng khi m rng cho cc
loi stent khc nhau th p sut n nh mc cng khc nhau. iu ny cho thy s nh
hng ca thit k stent ln p sut n nh mc.

Trang 26

VI. KT LUN
(1) S hi ha ca h thng phn phi stent ng vai tr quan trng n hiu qu
ca th thut. Ngoi vic m bo tnh tng thch sinh hc ca stent thng cng cc
tiu chun khc, nht thit phi thc hin nh gi p sut n nh mc ca bng. y l
mt trong nhng tiu chun m bo tnh an ton v hiu qu khi t stent. ngha
ca vic phn tch p sut n nh mc ca bng gip cho cc bc s iu tr bit thng
tin cn thit thc hin t stent v gim st kt qu tt hn.
Quy trnh thc hin:
a. u tin, lm y b nc bng nc sch, iu chnh nhit nc n nhit
37OC (gi tr nhit c th sai lch 0.2)
b. Tip theo, cho dung dch bm vo bng bng ng bm (Lu , trong bc thao
tc ny trnh lm h hi bng, nu c lp tc quay li bc a vi bng khc)
c. Nhn chm ton b bng vo bn nc
d. Gi nguyn bc c t nht trong vng 2 pht
e. Thi phng bng t p sut ban u cho n khi ti p sut m bng n (ghi
nhn li p sut bng v)
f. Tin hnh tng t t bc a n bc e i vi cc bng khc m bo c
ngha v mt thng k
g. Thc hin tnh ton p sut n nh mc ( chnh xc ng tin cy).
(2) Vic tm ra p sut n nh mc ca mi h thng phn phi ph thuc vo
vt liu (tng thch v khng tng thch) v cng ngh ch to bng. Bng cch bm
nc vo trong bng ri t vo trong bn nc 37 2OC, bt u bm bng t p sut
ban u cho n p sut m bng n, ghi nhn li kt qu v tin hnh thc hin lp li
(c ngha v mt thng k), tnh ton kt qu. Vic nh gi p sut n nh mc ca
bng l mt trong nhng ch tiu nh gi mc an ton v hiu qu khi s dng h
thng phn phi stent bng bng vo ng mch, cc nh gi ny phi thc hin theo
quy trnh nghim ngc m bo tt nht mc chnh xc, trnh sai st.

Trang 27

TI LIU THAM KHO


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applications of NiTi shape memory and superelastic alloys. Biomed Mater Eng
1996;6(4):267-89.
3. Nguyen KT, Su SH, Sheng A, Wawro D, Schwade ND, Brouse CF, et al. In
vitro hemocompatibility studies of drug-loaded poly-(L-lactic acid) fibers.
Biomaterials 2003;24:5191-201.
4. Matthews IP, Gibson C, Samuel AH. Sterilisation of implantable devices. Clin
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5. Lichtenfels, Frankini, & Cardozo. (2011). Stent graft infection. J. Vasc. Bras.
6. Sigwart et al. (1992). Coronary stents. 45-55 & 57-77.
7. Stent Materials and Manufacturing: Requirements and Possibilities /
Opportunities. ASM Materials & Processes for Medical Devices Conference
8-10 Sept. 2003, Anaheim, CA.
8. Caixeta A, et al. Clinical follow-up 3 years after everolimus- and paclitaxeleluting stents. JACC Cardiovasc Interv. 2010;3(12):12208.
9. Serruys PW, et al. A bioabsorbable everolimus-eluting coronary stent system
(ABSORB):

2-year

outcomes

and

results

from

multiple

imaging

methods. Lancet. 2009;


10. MedMarket Diligence report #C245, worldwide market for drug-eluting, bare
and other coronary stents. 2009;20082017.
11. In: Rutala WA, editor. Association for Professionals in Infection Control and
Epidemiology. DC.: Washington; 2001.
12. ISO TC 198. ISO/Draft International Standard, Aseptic processing of health
care products, Part 7: Alternate processes for atypical medical devices and
combination devices.
13. http://www.medscape.org/viewarticle/501397
14. http://www.bmj.com/content/345/bmj.e5170

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