iu tr ni mch cho nhng tn thng ng mch sau chn thng thn hay tn thng thn

do can thip y khoa.

Tm tt:

Thn l c quan d b tn thng hng th 3 trong chn thng, theo sau lch v gan. Phn
thng dng nh gi chn thng thn l phn ca Hip hi M v Phu thut Chn
thng (AAST). Phn ny nh gi tn thng thn da trn kch thc vt rch v s ln cn
ca n i vi rn thn. D ng-tnh mch v gi phnh l nhng tn thng mch mu do can
thip y khoa nh sinh thit hay phu thut trn thn chnh ch. Cch tip cn cc tn thng ng
mch thn thay i theo thi gian t hng can thip tch cc n theo di v iu tr bo tn,
hoc iu tr ni mch, bao gm phng php thuyn tc ng mch thn chn lc qua catheter
v t stent/mnh ghp stent. Trong bi vit ny, chng ti m t vai tr v cc mt k thut v
can thip ni mch trong iu tr tn thng ng mch sau chn thng hay tn thng do can
thip y khoa.

M u

Thn l c quan niu-sinh dc thng tn thng nht trong chn thng bng [24]. C ch chnh
gy ra tn thng thn l chn thng, do can thip y khoa, hay trong lc phu thut [9, 21]. Hu
ht cc tn thng do chn thng thng nh v khng gy nguy him ti tnh mng. Tn
thng thn c th c chia thnh cc loi sau: rch thn, dp thn, v tn thng mch mu
thn [9, 21, 23]. Tn sut tn thng mch mu thn do can thip y khoa ngy cng tng v cng
c nhiu th thut can thip nh phc hi ng mch thn hay t stent, cc th thut qua da
nh sinh thit, m thn ra da, tn si thn-niu qun, hay phu thut bo tn nephron [5, 6, 12,
19]. Cc du hiu hnh nh hc trong tn thng mch mu do can thip y khoa bao gm d ng-
tnh mch, gi phnh, bc tch ng mch, hay thot cn quang. Hu ht nhng tn thng ny t
lnh. Tuy nhin, chng c th gy chy mu lng nhiu, tiu mu gy nguy hi ti tnh mng hay
suy gim chc nng thn, v cn phi c x tr tc thi [5, 6, 12]. Ngy nay, cc hng tip cn
bo tn hay xm ln tn thiu ngy cng c a chung hn hng phu thut, bao gm th
thut thuyn tc ng mch qua catheter v t stent/mnh ghp stent [3-6, 8, 9, 12, 15, 17-21,
23]. T lu, iu tr ni mch l mt hng tip cn khng phu thut cc tn thng ng mch
thn v c nhiu li im nh hi phc nhanh, thi gian nm vin ngn v c th hot ng th
cht li nhanh chng. Mc ch ca bi vit ny nhm m t vai tr v cc kha cnh k thut ca
can thip ni mch trong vic iu tr cc tn thng ng mch sau chn thng v tn thng
thn do can thip y khoa.
Cn nhc chung v k thut

ln kt hoch iu tr, cn phi m t chnh xc ging mch mu, bao gm ng mch ch v

cc nhnh ca n, cng nh cn phi lm hnh nh hc chn lc thn b tn thng. Mt catheter
sheath introducer c s dng mt cch c h thng. nhng bnh nhn c ng mch xon
hay b x va ng mch, vic s dng mt sheath di (35 ti 45 cm) vi nh sheath c t vo
v tr xui dng t l m cho ng mch thn s to iu kin thun li cho vic t catheter
nhiu ln. Vic s dng catheter thng dng khu c 4 hoc 5 Fr v guidewire a nc khin cho
vic t catheter siu chn lc tr nn d hn v nhng thit b ny lm ta c th t vi catheter
ng trc vo catheter tip cn [6, 12, 19].

Vic chn la vt liu thuyn tc l rt quan trng trong vic iu tr cc tn thng mch mu
hiu qu. Vt liu c la chn da trn nhng c s nh sau: v tr, kch thc, mu dng chy
ca mch mu s b bt tc, sn c ca vt liu, v kinh nghim ca nh hnh nh hc can thip
[4]. Mch mu qua da bng thuyn tc chn lc bng xon kim loi l la chn u tin trong
iu tr chy mu ng mch thn. Thuyn tc siu chn lc cng xa cng tt gi tn thng
nhu m mc ti thiu, t nht l phi ngang mc ng mch gian thu. iu ny c th c
thc hin bng vi catheter v vt liu thuyn tc l vi xon kim loi. Khuyt im chnh ca thuyn
tc bng xon kim loi l phi cn nhiu hn mt xon kim loi c th bt tc , v do lm
tng chi ph v thi gian ca th thut. V nhng l do ny, cc vt liu thuyn tc dng lng nh
keo n-butyl cyanoacrylate (NBCA) hay Onyx c th rt hu ch. Mui cyanoacrylates c u im
l nht thp nn d tip vo nhng catheter nh v xon nhiu vng. Vic s dng keo NBCA
nhng bnh nhn huyt ng khng n nh ang rt c quan tm v n cho php cm mu
nhanh hn nhng loi vt liu thuyn tc khc [4-6, 18].

Chn thng mch mu thn

Tn thng thn xy ra khong 1-5% s bnh nhn b chn thng [2]. Chng thng c xc
nh trn hnh nh chp ct lp vi tnh v phn theo AAST thnh 5 phn khc nhau (Hnh 1):
1 = dp thn hoc mu t khng lan di bao thn m khng c rch nhu m, 2 = mu t
chu thn khng lan hoc rch v thn (<1 cm) m khng c thot nc tiu, 3 = rch v thn
(>1 cm) v khng c thot nc tiu, 4 = rch v thn lan vo h thng ng gp (ghi nhn trn
hnh nh hc l thot mch cn quang) hoc tn thng ng mch hoc tnh mch phn thu (ghi
nhn trn hnh nh hc l nhi mu phn thu) hoc tn thng ng mch hoc tnh mch thn
chnh cng vi mt khi mu t khu tr, 5 = thn v nt, t la cung thn, hoc huyt khi
ng mch thn chnh [9]. iu tr cc tn thng thn do chn thng bng phu thut v khng
phu thut l vn vn cn ang tranh lun nhiu nm nay. Theo truyn thng, cc tn thng
thn cao s c iu tr bng m thm st hoc phu thut ct thn. Tuy nhin, vi nhng
tin b v x l hnh nh ct lp vi tnh v cc k thut xm ln ti thiu, iu tr khng phu thut
tr thnh tiu chun mi [8]. Ch nh thuyn tc ng mch qua catheter sau chn thng
khc nhau mi trung tm. Trong nhng trng hp c chn thng m xuyn, thuyn tc ng
mch qua catheter thng l phng tin thay th phu thut u tay. i vi chn thng, vai
tr tng i ca vic iu tr ch i, thuyn tc, v phu thut c th ph thuc v tn
thng v tng trng ca bnh nhn [23]. Thng thng, thuyn tc c thc hin iu tr
cc tn thng thn phn thp v cc tn thng m xuyn c pht hin trn hnh nh ct
lp vi tnh (Hnh 2). Vic s dng liu php ni mch trong ng cnh chn thng thn 5 v
huyt ng bt n vn cn l vn ang tranh ci, vi cc bo co y mu thun t thnh cng
hon ton hoc tht bi hon ton [7, 8, 13, 22]. Tuy nhin, thuyn tc ng mch qua catheter
cng ngy c thc hin nhiu trung tm x tr cc tn thng thn phn cao. Mt lot
cc tiu chun lm sng c xut lm cc nhn t chnh d on nhu cu thuyn tc
thn, bao gm phn AAST, c ch tn thng, tnh trng n nh ca bnh nhn trn lm sng,
cc tn thng tng phi hp, bi v trn hnh nh ct lp vi tnh c th c nhiu du hiu khc
nhau, nh chy mu ng mch ang tip din, kch thc vin khi mu t chu thn, v s mt
lin tc ca mc Gerota. 3 ch nh sau y nn xem xt phu thut: chy mu gy nguy him ti
tnh mng, t la cung thn ( 5), v khi mu t sau phc mc khng khu tr ang lan rng
[9]. Thuyn tc ng mch qua catheter c th gim t l phu thut ct thn ln ti 78% i vi
tn thng 4 v 83% vi tn thng 5 [23]. Tuy nhin, i vi nhng tn thng 4 v 5
th c th phi cn can thip ni mch ln th hai iu tr chy mu ti pht. Da trn
nhng khuyn co ny, mch mu chn on v thuyn tc tr thnh hng tip cn iu
tr trong vic x tr tn thng thn do chn thng. Hai liu php ni mch chnh c a ra
bi cc nh hnh nh hc can thip l thuyn tc v t stent cc ng mch thn b tn thng.
Thuyn tc ng mch siu chn lc c th c s dng nhng ca rch ng mch thn, d
ng-tnh mch, gi phnh bng nhng vt liu thuyn tc khc nhau [1, 10, 11, 14, 16, 25]. Lin
quan ti iu tr bc tch ng mch thn, cc nghin cu gn y ng h vic t stent ni mch
iu tr cc vt rch lp o trong m nhng vt rch ny gy ra bc tch hoc hp lng (Hnh 3,
4) [15, 18]. Trong trng hp rch ng mch gn, stent ph (covered stents) c th c s
dng.
Hnh 2. Thuyn tc tn thng ng mch cp cu sau chn thng mt ph n 51 tui. (A)
Thot mch cht cn quang (tn thng dng ging gi phnh) nhnh di xa-cc, mch mu
chn lc cho thy ang chy mu tip din (mi tn); (B) thuyn tc chn lc ng mch nui bng
vi xon kim loi c th tho ri; (C) mch mu chng cho thy bt tc hon ton v chn lc
nhnh ang chy mu, khng cn chy mu.

Hnh 3. X tr ni mch mun cho tn thng bc tch ng mch thn sau chn thng mt
ngi n ng 63 tui. (A) Cc du hiu cho thy bc tch thnh dng khng bt tc ca ng
mch thn xa bn phi v tn thng gi phnh hnh thnh th pht; (B) mch mu sau khi t
stent ph mch vnh cho thy ng mch thn bnh thng.
Hnh 4. Chy mu tip din sau ghp thn mt ngi ph n 46 tui. (A) Mch mu chn lc
cho thy thot mch cn quang ang tip din t phn thn ca cc di nhnh ng mch phn
thu trn thn ghp; (B) t mnh ghp stent mch vnh chn lc; (C) Ngng chy mu hon ton
trn mch mu sau th thut cho thy chc nng ng mch chnh vn c bo ton.

Tn thng mch mu thn do can thip y khoa

Tn thng vng lng di, nht l vt m, sinh thit thn qua da, hay cc phu thut bo tn
nephron c th gy ra nhng tn thng mch mu v t gy ra nhiu bin chng khc nhau
[2, 5]. Thuyn tc l liu php ph hp cho nhng ca nh vy.

Trong giai on cp

Vi gi sau chn thng, v c th khng cm mu c nn c th dn ti tnh trng sc. ng

mch cp cu thng s cho thy ng mch b tn thng v ch ang thot mch. Vic bt
tc ng mch b tn thng bng cc ht tr, cc vt liu c th ti hp thu, keo hoc vi xon kim
loi da trn hnh thi hc ca tn thng (Hnh 5). Thng s cm mu thnh cng. Mt s
trng hp chy mu ti pht c bo co khi s dng vt liu ti hp thu [4]. Trong nhng
trng hp ny, cn lp li thuyn tc cm mu. Nhi mu thn t nhng can thip trn
thng khng thy trn hnh nh hc hoc khng ng k. K thut ny khng my tch cc v bo
tn c nhu m thn [6].
Hnh 5. Gii phnh ln trong nhu m thn tri sau phu thut bo tn nephron mt bnh nhn
58 tui. (A) Hnh nh ct lp vi tnh cho thy khi gi phnh trong thn tri; (B) t catheter siu
chn lc vo nhnh ng mch nui v gi phnh; (C) kt qu sau khi thuyn tc chn lc ti phnh
v ng mch nui bng Onyx cho thy tn thng hon ton b xo m km nhi mu nh
vng v.

Hnh 6. Tiu mu lng ln km sc gim th tch 2 gi sau khi sinh thit thn qua da mt ph
n 56 tui. (A,B) S hin din ca d ng mch-i thn trn phim mch mu thn cp cu
km vi ho nhanh khoang tit niu; (C) thuyn tc bng vi xon kim loi hai mch mu bt
thng gy ra tiu mu; (D) bt tc hon ton l d v ngng chy mu trn phim mch mu
sau thuyn tc.

Trong giai on hu cp
Vn chnh ca giai on hu cp l tiu mu dai dng qua s hnh thnh ca mt d ng-tnh
mch (Hnh 6). iu ny rt thng xy ra sau sinh thit thn, v thng n s t ng trong mt
vi ngy. Nu nh n vn tn ti hn mt tun th c th gy kh khn cho vic hi phc. iu tr
qua da bao gm gy bt tc mch mu bt thng l nguyn nhn gy tiu mu [19]. Mu mt
thng t v thng lin quan ti ng mch ngoi bin. Thuyn tc c th c thc hin bng
cc ht tr v 1 hoc 2 vi xon kim loi. Lot do nm lu c th xut hin vo ngy th 10. Cc
mu ng ngn mu chy ni m kim c th b tch ri lm xut huyt nng t ngt, tnh trng
ny c th nghim trng nu nh bnh nhn khng cn c theo di. iu ny cng ng trong
giai on cp, thuyn tc cp cu c bit hu dng v n cm mu v nga bin chng [5, 6]

Bin chng mun

D ng-tnh mch v gi phnh kh thng gp, v t l mi mc ca chng tng cng vi s ln

can thip qua da, sinh thit thn v cc th thut phu thut. D ng-tnh mch xy ra sau 15%
s ca sinh thit thn, nhng ch 4% ko di vi thng. Hu ht u t lnh [2, 5]. D ng tnh
mch cng c th xy ra sau phu thut ct thn nu nh ton b cun mch mu c ct chung
vi nhau. Quyt nh c khi phc tn thng ny hay khng ph thuc vo dng mu chy qua l
d (suy tim, tng huyt p), nguy c v trong trng hp gi phnh ln, v tiu mu ti pht.
Trong mt s trng hp nht nh, cc l d c khi phc nhm to iu kin cho nhng ln
sinh thit k tip. Hnh thi hc ca l d phi c kho st k trc thuyn tc (Hnh 7). S lin
thng gia ng mch v tnh mch , hoc gi phnh nu c l mc tiu chnh ca th thut bt tc.
K thut chnh l vic t cc xon kim loi (Hnh 8). Mt nt bt tc i khi cng c t vo
ng mch ang cp mu [4]. Cc gi phnh khng thng thng c bt tc bng xon kim loi.
Trong hu ht cc trng hp u c th bo tn ging mch mu xui dng v hu ht nhu m
thn. Thuyn tc l iu tr chn la cho nhng l d nh vy. Khng cn nghi ng g rng l kt
qu thuyn tc tt hn nhiu so vi kt qu sau phu thut. T l mi mc ca bin chng l thp
i vi i ng chuyn nghip [2, 6].

Hnh 7. Tng huyt p ng mch trng din mt bnh nhn 43 tui 1 nm sau sinh thit thn
d ghp qua da. (A) ng mch chn lc: c l d ng-tnh mch ln nhnh phn thu cc
trn ca ng mch thn trn thn ghp v gi phnh (mi tn mu en) km shunt ng-tnh
mch ng k (u mi tn) v y tnh mch sm (mi tn mu trng). Lu s vng mt ca
hnh nh thn (nephrogram); (B) Phim mch mu chng sau thuyn tc chn lc ng mch
n bng xon kim loi 0.035 inch: bt tc hon ton cung ca ti phnh v l d, ci thin hnh
nh thn ; (C) Phim mch mu sau thuyn tc (pha nhu m): nhi mu thn < 10% vng nhu
m thn (mi tn)

Bin chng

au

Cn au thng khi pht sau thuyn tc v c th ko di t 1 ti 5 ngy tu thuc vo th tch

nhu m b nh hng. Lc iu tr d ng-tnh mch th gn nh bnh nhn khng au. Bnh
nhn phi c iu tr au hp l trc v sau th thut [23]

Tng huyt p

Thng gp tng huyt p ng mch thong qua v c th ko di ln ti 24 gi. C nguy c tng

huyt p vnh vin khi c tn d m thn thiu mu m khng phi l nhi mu.

Suy thn

Thc hin cc th thut c km theo cc cht cha i-t c th gy suy gim chc nng thn. Bnh
nhn phi c ung nc y trc bt k th thut thuyn tc no [17].

Hi chng sau thuyn tc

Hi chng ny gn nh khng th trnh khi trong trng hp ph hu m thn, bao gm cc

triu chng bun nn, nn i, st v au bng. Thng thng nng ph thuc th tch m nhi
mu. Hi chng ny thng i km vi tc rut do lit rut. Xt nghim sinh ho c th cho thy
tng bch cu. Hi chng ny thng thuyn gim sau vi ngy sau khi iu tr triu chng [6, 7].

Tiu mu

Sau thuyn tc c th c tiu mu mc trung bnh. iu ny c lin quan ti nhi mu do xut

huyt v thng s ht trong vng 24 ti 48 gi.

Nhim trng

C nguy c xy ra cc t bng pht ca nhim trng tim n c sn, iu ny c ngha l nh can

thip hnh nh hc phi nm r bnh n ca bnh nhn. Xt nghim t bo-vi khun hc phi
c thc hin thng quy trc khi can thip, tr trng hp phi thc hin th thut khn
cp: nhim trng ng niu hin ti khng kim sot l chng ch nh ca thuyn tc ng mch
qua catheter. Cc bong bng kh nh c tm thy trn hnh nh ct lp vi tnh sau can thip
nhng bnh nhn nhim trng. Thng nhng bong bng kh ny xy ra t ngy th 3 ti ngy
th 16 sau thuyn tc. Chng khng nht thit gi mt p-xe, nhng chng c th tng ng
vi nhi mu v trng bnh thng [5, 6].

Thuyn tc sai ch
Lun c th xy ra vi bt k loi vt liu no. Lun c ri ro ng k thuyn tc phi do xon kim
loi, ht tr vnh vin hay keo trong trng hp d ng-tnh mch. C th ly vi xon kim loi
bng li theo k thut Lasso hoc bng phu thut [4].

Cc bin chng khc

Cng ging nh cc th thut ni mch khc, thuyn tc v t stent lun mang theo ri ro hnh
thnh khi mu t ti im m kim, bc tch ng mch, huyt khi, v ng mch, thuyn tc
xa, phn ng phn v, sc, qu ti dch v suy thn.

Kt lun

Tom li, trong mt vi thp k gn y, thuyn tc ng mch qua catheter tr thnh liu php
u tay iu tr chn thng thn c phn AAST thp v cng ngy cng tr nn thng dng
vi cc tn thng thn phn cao hn. Thuyn tc ng mch qua catheter i din cho cc
bin php can thip an ton v hiu qu cm chy mu ng mch tt trong ng cnh tn
thng mch mu thn do can thip y khoa, v c th gim t l bin chng v t vong lin quan.
Mc ch chnh ca vic thuyn tc l n nh huyt ng cho bnh nhn. Vi bt c ch nh no,
thuyn tc ng mch thn cn c hi chn bng tip cn a chuyn khoa c th thit lp k
vng v cc mc ch trn lm sng.

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