{"id":1898,"date":"2013-04-05T12:09:42","date_gmt":"2013-04-05T12:09:42","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1898"},"modified":"2013-06-10T16:56:57","modified_gmt":"2013-06-10T16:56:57","slug":"1-diagnostika-arterialnich-a-zilnich-onemocneni","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1898","title":{"rendered":"1 Diagnostika arteri\u00e1ln\u00edch a \u017eiln\u00edch onemocn\u011bn\u00ed"},"content":{"rendered":"<p style=\"text-align: justify;\">Typick\u00fdm zad\u00e1n\u00edm pro c\u00e9vn\u00edho chirurga je stanoven\u00ed diagn\u00f3zy s navr\u017een\u00edm terapeutick\u00e9ho pl\u00e1nu u c\u00e9vn\u00edch onemocn\u011bn\u00ed. Z anamn\u00e9zy a fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed je schopen zhodnotit, kter\u00fd c\u00e9vn\u00ed syst\u00e9m je po\u0161kozen (arteri\u00e1ln\u00ed, \u017eiln\u00ed, lymfatick\u00fd) a zda se jedn\u00e1 o stav akutn\u00ed nebo chronick\u00fd. Z n\u00e1lezu vypl\u00fdv\u00e1 bu\u010f pot\u0159eba akutn\u00edho o\u0161et\u0159en\u00ed stavu, nebo vznik\u00e1 prostor k dal\u0161\u00edmu vy\u0161et\u0159ov\u00e1n\u00ed.Z\u00e1sadn\u00ed je z\u00edsk\u00e1n\u00ed kvalitn\u00ed a podrobn\u00e9 anamn\u00e9zy. Typickou symptomatologii arteri\u00e1ln\u00edch nebo \u017eiln\u00edch onemocn\u011bn\u00ed p\u0159edstavuj\u00ed: bolest, \u00fanavnost a slabost, neurosenzitivn\u00ed pot\u00ed\u017ee (pocit tepla, chladu, sn\u00ed\u017een\u00e1 citlivost nebo naopak hypersenzitivita), porucha zbarven\u00ed, otok, ulcera a ztr\u00e1ty tk\u00e1n\u011b (nekr\u00f3zy), varikozity. Je nutn\u00e9 zhodnocen\u00ed dynamiky pot\u00ed\u017e\u00ed (akutn\u00ed nebo chronick\u00e9), progrese pot\u00ed\u017e\u00ed od po\u010d\u00e1tku jejich vzniku a jejich lokalizace (jednostrann\u00e9, oboustrann\u00e9, proxim\u00e1ln\u00ed, dist\u00e1ln\u00ed). Nemocn\u00fd je schopen vyj\u00e1d\u0159it z\u00e1vislost pot\u00ed\u017e\u00ed v souvislosti s b\u011b\u017en\u00fdm denn\u00edm \u017eivotem, nap\u0159. bolest po n\u00e1maze, nebo pop\u00ed\u0161e \u00falevov\u00e9 polohy p\u0159i bolestech.<\/p>\n<h5>ARTERI\u00c1LN\u00cd ONEMOCN\u011aN\u00cd<\/h5>\n<h6>ANAMN\u00c9ZA<\/h6>\n<ul>\n<li style=\"text-align: justify;\">Odb\u011br anamn\u00e9zy ve v\u0161ech jej\u00edch \u010d\u00e1stech m\u00e1 spolu s fyzik\u00e1ln\u00edm vy\u0161et\u0159en\u00edm z\u00e1sadn\u00ed v\u00fdznam pro stanoven\u00ed kone\u010dn\u00e9 diagn\u00f3zy. V anamn\u00e9ze dominuje bolest a diskomfort.\n<ul>\n<li>N\u00e1hl\u00e1 bolest akutn\u00edho c\u00e9vn\u00edho uz\u00e1v\u011bru, 6P: pain, pallor, pulselessness, paresthesias, paralysis, poikilothermy (bolest, bledost, absence pulsace, parestezie, paral\u00fdza, chlad, resp. zm\u011bna teploty kon\u010detiny ve vztahu k okol\u00ed).<\/li>\n<li>Bolest n\u00e1mahov\u00e1, Fontainova klasifikace II (klaudikace \u2013 zhodnotit typ, lokalizace, klaudika\u010dn\u00ed interval).<\/li>\n<li>Klidov\u00e1 ischemick\u00e1 bolest, Fontainova klasifikace III (typick\u00e9 je zhor\u0161en\u00ed v noci), \u00falevov\u00e1 poloha \u2013 sv\u011b\u0161en\u00ed kon\u010detiny.<\/li>\n<li>Diferenci\u00e1ln\u00ed diagnostika bolesti: lumbalgie, ev. s ko\u0159enov\u00fdm dr\u00e1\u017ed\u011bn\u00edm, neuralgie n. ischiadicus nebo ortopedick\u00e1 etiologie \u2013 artr\u00f3za ky\u010deln\u00edho nebo kolenn\u00edho kloubu. P\u0159i klidov\u00fdch bolestech je nutn\u00e9 odli\u0161it diabetickou neuropatii a z\u00e1n\u011btliv\u00e9 procesy v ischemick\u00e9 tk\u00e1ni.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">C\u00edlen\u00e9 zam\u011b\u0159en\u00ed na rizikov\u00e9 faktory: kou\u0159en\u00ed, hypertenze, diabetes mellitus, nadv\u00e1ha, nedostatek pohybu, metabolick\u00e1 onemocn\u011bn\u00ed. Zhodnotit aktu\u00e1ln\u00ed medikament\u00f3zn\u00ed terapii.<\/li>\n<li style=\"text-align: justify;\">Celkov\u00e9 zhodnocen\u00ed nemocn\u00e9ho \u2013 jeho pohyblivost v dob\u011b anamn\u00e9zy, prim\u00e1rn\u011b imobiln\u00ed nemocn\u00fd, nap\u0159. po CMP, nen\u00ed indikovan\u00fd k v\u00fdkonu. Naopak nemocn\u00fd, kter\u00fd ohro\u017eenou kon\u010detinu, i kdy\u017e jen limitovan\u011b, vyu\u017e\u00edval, je indikov\u00e1n k chirurgick\u00e9mu nebo endovaskul\u00e1rn\u00edmu v\u00fdkonu.<\/li>\n<\/ul>\n<h6 style=\"text-align: justify;\">FYZIK\u00c1LN\u00cd VY\u0160ET\u0158EN\u00cd<\/h6>\n<ul>\n<li style=\"text-align: justify;\">Inspekce\n<ul style=\"text-align: justify;\">\n<li>Projevy ischemie: bledost nebo lividita k\u016f\u017ee,\u00a0ztr\u00e1ta ochlupen\u00ed, svalov\u00e9 atrofie, ulcerace, nekr\u00f3zy (Fontainova klasifikace IV) (fotogalerie 1a).<\/li>\n<li>Projevy jin\u00fdch onemocn\u011bn\u00ed: otoky, varixy, dermat\u00f3zy, chronick\u00e1 \u017eiln\u00ed nedostate\u010dnost, post-trombotick\u00fd syndrom, such\u00e1 olupuj\u00edc\u00ed se k\u016f\u017ee u DM.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Zhodnocen\u00ed pulzace v typick\u00fdch lokalizac\u00edch \u2013\u00a0kvalita pulzu, z\u00e1sadn\u00ed je stranov\u00e9 srovn\u00e1n\u00ed. Z hlediska fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed se jedn\u00e1 o pohmat a lze takto vy\u0161et\u0159it (poznat) v\u00fddu\u0165.<\/li>\n<li style=\"text-align: justify;\">Poslech nad zdrav\u00fdmi arteriemi: nen\u00ed sly\u0161et \u0161elest,\u00a0ten je projevem patologick\u00e9ho procesu (typick\u00fd p\u0159ikarotick\u00fdch sten\u00f3z\u00e1ch).<\/li>\n<li style=\"text-align: justify;\">B\u011bh\u00e1tko (treat tester): umo\u017en\u00ed objektivizaci \u00fadaj\u016f\u00a0nemocn\u00e9ho o jeho schopnosti z\u00e1t\u011b\u017ee. Ch\u016fze je nastavena na standardizovan\u00e9 podm\u00ednky, 3 km\/hod,stoup\u00e1n\u00ed 12% do dosa\u017een\u00ed pot\u00ed\u017e\u00ed (klaudikace). Zji\u0161t\u011bn\u00e1 vzd\u00e1lenost odpov\u00edd\u00e1 asi trojn\u00e1sobku skute\u010dn\u00e9ho \u00faseku za fyziologick\u00fdch podm\u00ednek.<\/li>\n<\/ul>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\"><strong>Fotogalerie 1a: obraz ischemie<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_021.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Akutn\u00ed ischemie PDK\" alt=\"Akutn\u00ed ischemie PDK\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_021.png\" width=\"200\" height=\"218\" \/><\/a><p class=\"wp-caption-text\">Akutn\u00ed ischemie PDK<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_022.png\"><img decoding=\"async\" title=\"Chronick\u00e1 ischemie LDK\" alt=\"Chronick\u00e1 ischemie LDK\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_022.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Chronick\u00e1 ischemie LDK<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_023.png\"><img decoding=\"async\" title=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na palce\" alt=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na palce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_023.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na palce<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_024.png\"><img decoding=\"async\" title=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, nekr\u00f3za dorsa nohy\" alt=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, nekr\u00f3za dorsa nohy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_024.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, nekr\u00f3za dorsa nohy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_026.png\"><img decoding=\"async\" title=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na prstu, stav po snesen\u00ed prstu\" alt=\"Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na prstu, stav po snesen\u00ed prstu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_026.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Chronick\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br, gangr\u00e9na prstu, stav po snesen\u00ed prstu<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_025.png\"><img decoding=\"async\" title=\"Viz p\u0159edchoz\u00ed\" alt=\"Viz p\u0159edchoz\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_025.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Viz p\u0159edchoz\u00ed<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>P\u0158\u00cdSTROJOV\u00c1 VY\u0160ET\u0158EN\u00cd<\/h6>\n<ul>\n<li style=\"text-align: justify;\">Dopplersonografie hodnot\u00ed pr\u016ftok arteri\u00e1ln\u00edm \u0159e\u010di\u0161t\u011bm a dod\u00e1v\u00e1 podklady k v\u00fdpo\u010dtu ABI (anklebrachial pressure index, ev. DI \u2013 dopplerindex). ABI je pom\u011br dvou m\u011b\u0159en\u00fdch TK. Pou\u017eit\u00e9 hodnoty jsou TK, p\u0159i kter\u00e9m vymiz\u00ed pulsace na arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti ve v\u00fd\u0161i hlezna p\u0159i dopplersonografii. Dal\u0161\u00ed hodnotou je krevn\u00ed tlak na pa\u017ei. Pom\u011br tlak\u016f vyjad\u0159uje stupe\u0148 poruchy prokrven\u00ed periferie (hodnoty pod 1). Zkreslen\u00e9 v\u00fdsledky jsou u diabetick\u00e9 angiopatie, kdy skler\u00f3za medie br\u00e1n\u00ed kompresi man\u017eetou a hodnoty jsou fale\u0161n\u011b nad 1. Kritick\u00e1 kon\u010detinov\u00e1 ischemie vznik\u00e1 p\u0159i hodnot\u00e1ch TK ve v\u00fd\u0161i hlezna pod 50 mm Hg.<\/li>\n<li style=\"text-align: justify;\">Barevn\u00e1 duplexn\u00ed sonografie zobraz\u00ed neinvazivn\u011b sten\u00f3zy a uz\u00e1v\u011bry c\u00e9vn\u00edho \u0159e\u010di\u0161t\u011b a zobraz\u00ed tak\u00e9 morfologii c\u00e9vn\u00ed st\u011bny. Rozpozn\u00e1 a zhodnot\u00ed arteri\u00e1ln\u00ed embolizace a tromb\u00f3zy. U n\u011bkter\u00fdch arteri\u00e1ln\u00edch onemocn\u011bn\u00ed (nap\u0159. sten\u00f3zy a uz\u00e1v\u011bry a. carotis) lze na jej\u00edm z\u00e1klad\u011b indikovat chirurgickou nebo endovaskul\u00e1rn\u00ed l\u00e9\u010dbu.<\/li>\n<li style=\"text-align: justify;\">Intraarteri\u00e1ln\u00ed digit\u00e1ln\u00ed subtrak\u010dn\u00ed angiografii (DSA) lze z hlediska kvality zobrazen\u00fdch n\u00e1lez\u016f pova\u017eovat za \u201ezlat\u00fd standard\u201c. Metoda je invazivn\u00ed (intraarteri\u00e1ln\u00ed aplikace), nemocn\u00fd je zat\u00ed\u017een rtg z\u00e1\u0159en\u00edm, dal\u0161\u00edm rizikem je pod\u00e1n\u00ed kontrastn\u00ed l\u00e1tky s rizikem alergick\u00e9 reakce. Kontrastn\u00ed l\u00e1tka tak\u00e9 omezuje pou\u017eit\u00ed metody u nemocn\u00fdch s ledvinnou nedostate\u010dnost\u00ed. Nov\u00e1 generace kontrastn\u00edch l\u00e1tek (neionick\u00e9, isoosmol\u00e1rn\u00ed) tento nedostatek \u010d\u00e1ste\u010dn\u011b odstra\u0148uje. Nelze ji pova\u017eovat za metodu prvn\u00ed volby k vy\u0161et\u0159en\u00ed arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b, jej\u00ed v\u00fdznam je v do\u0161et\u0159en\u00ed nemocn\u00e9ho p\u0159ed endovaskul\u00e1rn\u00edm z\u00e1krokem, kter\u00fd p\u0159\u00edmo na DSA navazuje (tedy p\u0159\u00edm\u00fd p\u0159echod z diagnostiky do terapie) (fotogalerie 1b).<\/li>\n<li style=\"text-align: justify;\">DSA je dnes sou\u010d\u00e1st\u00ed tzv. hybridn\u00edch opera\u010dn\u00edch s\u00e1l\u016f, kdy na super\u010dist\u00e9m kardiovaskul\u00e1rn\u00edm s\u00e1lu je zabudov\u00e1na pln\u011bhodnotn\u00e1 angiolinka. Tato kombinace umo\u017e\u0148uje v jedn\u00e9 dob\u011b prov\u00e1d\u011bt chirurgick\u00e9 a endovaskul\u00e1rn\u00ed v\u00fdkony. Nemocn\u00fd je vystaven men\u0161\u00ed opera\u010dn\u00ed z\u00e1t\u011b\u017ei a sou\u010dasn\u011b se sni\u017euj\u00ed n\u00e1klady na p\u00e9\u010di.<\/li>\n<li style=\"text-align: justify;\">Intraven\u00f3zn\u00ed digit\u00e1ln\u00ed subtrak\u010dn\u00ed angiografie je obsolentn\u00ed.<\/li>\n<li style=\"text-align: justify;\">NMR ag je angiografie pomoc\u00ed NMR s pod\u00e1n\u00edm kontrastn\u00ed l\u00e1tky (gadolinium). Metoda se pova\u017euje za neinvazivn\u00ed, proto\u017ee se kontrastn\u00ed l\u00e1tka pod\u00e1v\u00e1 intraven\u00f3zn\u011b, dal\u0161\u00ed jej\u00ed p\u0159ednost\u00ed je nep\u0159\u00edtomnost radiace. Umo\u017e\u0148uje v jedn\u00e9 dob\u011b vy\u0161et\u0159it rozs\u00e1hl\u00e9 \u00faseky t\u011bla (subfrenick\u00e1 aorta \u2013 periferie kon\u010detin). Metoda nen\u00ed pou\u017eiteln\u00e1 u nemocn\u00fdch s PM nebo s defibril\u00e1tory. U nemocn\u00fdch s kovov\u00fdm materi\u00e1lem (traumatologie) v t\u011ble je t\u0159eba po\u010d\u00edtat se vznikem artefakt\u016f. Nen\u00ed vhodn\u00e1 u nemocn\u00fdch s chronickou ledvinnou nedostate\u010dnost\u00ed (fotogalerie 1c,1e).<\/li>\n<li style=\"text-align: justify;\">CT ag p\u0159edstavuje diagnostickou metodu pro\u00a0zhodnocen\u00ed arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b a k indikaci l\u00e9\u010dby. Je m\u00e9n\u011b invazivn\u00ed ne\u017e DSA a jej\u00ed p\u0159ednost\u00ed je rychlost vy\u0161et\u0159en\u00ed. Limitac\u00ed je pod\u00e1n\u00ed kontrastn\u00ed l\u00e1tky a radia\u010dn\u00ed z\u00e1t\u011b\u017e. Zhodnocen\u00ed n\u00e1lezu b\u00fdv\u00e1 komplikov\u00e1no zobrazen\u00edm zv\u00e1penat\u011bl\u00fdch plak\u016f arteri\u00e1ln\u00ed st\u011bny, kter\u00e9 zt\u011b\u017euj\u00ed zhodnocen\u00ed re\u00e1ln\u00e9ho stupn\u011b posti\u017een\u00ed arteri\u00e1ln\u00edho lumen (stupe\u0148 sten\u00f3zy).Vzhledem k roz\u0161\u00ed\u0159en\u00ed CT techniky je dostupn\u011bj\u0161\u00ed ne\u017e NMR ag (fotogalerie 1d).<\/li>\n<\/ul>\n<h6>DIAGNOSTICK\u00dd SOUHRN<\/h6>\n<p style=\"text-align: justify;\">Na z\u00e1v\u011br vy\u0161et\u0159en\u00ed arteri\u00e1ln\u00edho syst\u00e9mu mus\u00ed b\u00fdt vytvo\u0159en diagnostick\u00fd souhrn a funk\u010dn\u00ed klasifikace nemocn\u00e9ho s kon\u010detinovou ischemi\u00ed. Nejjednodu\u0161\u0161\u00ed forma je Fontainova klasifikace nemocn\u00fdch s chronickou kon\u010detinovou ischemi\u00ed.U nemocn\u00fdch s akutn\u00ed kon\u010detinovou ischemi\u00ed je t\u0159eba stav \u0159e\u0161it urgentn\u011b. V dobr\u00e9 v\u00ed\u0159e indikovan\u00e1 vy\u0161et\u0159en\u00ed mohou v\u00e9st k pozdn\u00ed indikaci k v\u00fdkonu.<\/p>\n<p><strong>Fontainova klasifikace:<\/strong><\/p>\n<ul>\n<li style=\"text-align: justify;\">\u00a0<span style=\"text-decoration: underline;\">I. stupe\u0148:<\/span><br \/>\ntepenn\u00e9 posti\u017een\u00ed bez klinick\u00fdch projev\u016f. Jedn\u00e1 se obvykle o n\u00e1hodn\u00fd n\u00e1lez p\u0159i celkov\u00e9m c\u00e9vn\u00edm vy\u0161et\u0159en\u00ed. Nep\u0159edpokl\u00e1d\u00e1 se endovaskul\u00e1rn\u00ed nebo chirugick\u00e1 l\u00e9\u010dba, nen\u00ed tedy indikov\u00e1na angiografie. Je indikov\u00e1no konzervativn\u00ed l\u00e9\u010den\u00ed se zam\u011b\u0159en\u00edm na zm\u00edrn\u011bn\u00ed progrese onemocn\u011bn\u00ed.<\/li>\n<li style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">II. stupe\u0148:<\/span><br \/>\nperiodick\u00e1 bolest svalstva po z\u00e1t\u011b\u017ei v d\u016fsledku tepenn\u00e9 nedostate\u010dnosti. Jedn\u00e1 se o manifestn\u00ed funk\u010dn\u00ed ischemii. P\u0159i zat\u00ed\u017een\u00ed se zvy\u0161uj\u00ed metabolick\u00e9 n\u00e1roky sval\u016f a nedostate\u010dn\u00fd p\u0159\u00edtok krve p\u0159i tepenn\u00e9m onemocn\u011bn\u00ed nen\u00ed schopen metabolick\u00e9 n\u00e1roky uspokojit. Vznikaj\u00ed tzv. intermitentn\u00ed klaudikace. Bolest je zp\u016fsobena nahromad\u011bn\u00edm kysel\u00fdch metabolit\u016f ve svalech. Bolest vznik\u00e1 po ur\u010dit\u00e9m intervalu ch\u016fze a po zastaven\u00ed b\u011bhem n\u011bkolika minut odezn\u00ed. P\u0159i vy-\u0161et\u0159en\u00ed nemocn\u00e9ho je t\u0159eba lokalizovat bolest a zhodnotit interval v metrech, kdy bolest nastoup\u00ed. Klaudikace mohou b\u00fdt dle lokalizace h\u00fd\u017e\u010fov\u00e9, stehenn\u00ed,typick\u00e9 jsou l\u00fdtkov\u00e9 a plant\u00e1rn\u00ed. Lokalizace bolest\u00ed v\u00fdrazn\u011b informuje o lokalizaci obliteruj\u00edc\u00edch zm\u011bn.<\/li>\n<li style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">III. stupe\u0148:<\/span><br \/>\nklidov\u00e9 bolesti bez patrn\u00fdch trofick\u00fdch zm\u011bn. Navazuj\u00ed na klaudika\u010dn\u00ed bolesti a jsou projevem nedostate\u010dn\u00e9ho z\u00e1soben\u00ed tk\u00e1n\u00ed i v klidu. B\u00fdvaj\u00ed v akr\u00e1ln\u00edch \u010d\u00e1stech kon\u010detin a v\u011bt\u0161inou v noci. \u00dalevu p\u0159in\u00e1\u0161\u00ed nemocn\u00fdm sv\u011b\u0161en\u00ed kon\u010detiny nebo ch\u016fze. Dal\u0161\u00edm projevem jsou svalov\u00e9 atrofie z ne\u010dinnosti a par\u00e9zy nerv\u016f.<\/li>\n<\/ul>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 1b: intraarteri\u00e1ln\u00ed DSA LDK<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff; text-align: center;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_030.gif\"><img loading=\"lazy\" decoding=\"async\" title=\"AFS vlevo\" alt=\"AFS vlevo\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_030.gif\" width=\"200\" height=\"200\" \/><\/a><p class=\"wp-caption-text\">AFS vlevo<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_029.gif\"><img decoding=\"async\" title=\"Uz\u00e1v\u011br a poplitea\" alt=\"Uz\u00e1v\u011br a poplitea\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_029.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Uz\u00e1v\u011br a poplitea<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_032.gif\"><img decoding=\"async\" title=\"Sklerotick\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" alt=\"Sklerotick\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_032.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Sklerotick\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_031.gif\"><img decoding=\"async\" title=\"Zbytkov\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" alt=\"Zbytkov\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_031.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Zbytkov\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">IV. stupe\u0148<\/span>:<br \/>\nvznikaj\u00ed trofick\u00e9 zm\u011bny, pokro\u010dil\u00e1 ischemie bezprost\u0159edn\u011b ohro\u017euje kon\u010detinu. Na ko\u017en\u00ed defekty (vstup infekce) navazuj\u00ed gangr\u00e9ny a infek\u010dn\u00ed komplikace. Nej\u010dast\u011bji jsou posti\u017eeny prsty nohy. V infikovan\u00e9m ter\u00e9nu vznikaj\u00ed flegmony a m\u016f\u017ee doj\u00edt k sepsi. P\u0159ed indikovan\u00fdm a pl\u00e1novan\u00fdm p\u0159\u00edstrojov\u00fdm vy\u0161et\u0159en\u00ed nemocn\u00e9ho je vhodn\u00e9 s n\u00edm fyzik\u00e1ln\u00ed n\u00e1lez podrobn\u011b probrat a informovat jej o dal\u0161\u00edm postupu. Nen\u00ed vz\u00e1cn\u00e1 situace, kdy nemocn\u00fd jakoukoliv invazivn\u00ed terapeutickou metodu odm\u00edtne, v t\u011bchto p\u0159\u00edpadech nem\u00e1 dal\u0161\u00ed do\u0161et\u0159ov\u00e1n\u00ed (nap\u0159. n\u011bkter\u00e1 forma ag) smysl.<\/li>\n<\/ul>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff; text-align: center;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 1c: NMR AG v rozsahu aorta \u2013 periferie kon\u010detin<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_035.gif\"><img decoding=\"async\" title=\"Sten\u00f3zy a uz\u00e1v\u011bry p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" alt=\"Sten\u00f3zy a uz\u00e1v\u011bry p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_035.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Sten\u00f3zy a uz\u00e1v\u011bry p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_034.gif\"><img decoding=\"async\" title=\"Uz\u00e1v\u011br AFS vlevo\" alt=\"Uz\u00e1v\u011br AFS vlevo\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_034.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Uz\u00e1v\u011br AFS vlevo<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_036.gif\"><img decoding=\"async\" title=\"Obraz b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b, vpravo kontaminace \u017eiln\u00edho syst\u00e9mu VMS\" alt=\"Obraz b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b, vpravo kontaminace \u017eiln\u00edho syst\u00e9mu VMS\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_036.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obraz b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b, vpravo kontaminace \u017eiln\u00edho syst\u00e9mu VMS<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>\u00a0Fotogalerie 1d: CT AG<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_039.jpg\"><img decoding=\"async\" title=\"Aorta a p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b, sklerotick\u00e9 zm\u011bny\" alt=\"Aorta a p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b, sklerotick\u00e9 zm\u011bny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_039.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Aorta a p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b, sklerotick\u00e9 zm\u011bny<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_038.jpg\"><img decoding=\"async\" title=\"Sten\u00f3zy spole\u010dn\u00e9 p\u00e1nevn\u00ed tepny vlevo\" alt=\"Sten\u00f3zy spole\u010dn\u00e9 p\u00e1nevn\u00ed tepny vlevo\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_038.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Sten\u00f3zy spole\u010dn\u00e9 p\u00e1nevn\u00ed tepny vlevo<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_041.jpg\"><img decoding=\"async\" title=\"Zevn\u00ed p\u00e1nevn\u00ed \u0159e\u010dist\u011b a stehenn\u00ed \u0159e\u010dist\u011b bez AS zm\u011bn\" alt=\"Zevn\u00ed p\u00e1nevn\u00ed \u0159e\u010dist\u011b a stehenn\u00ed \u0159e\u010dist\u011b bez AS zm\u011bn\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_041.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Zevn\u00ed p\u00e1nevn\u00ed \u0159e\u010dist\u011b a stehenn\u00ed \u0159e\u010dist\u011b bez AS zm\u011bn<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_040.jpg\"><img decoding=\"async\" title=\"Uz\u00e1v\u011bry b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b\" alt=\"Uz\u00e1v\u011bry b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_040.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Uz\u00e1v\u011bry b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 1e: NMR AG<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<h6><\/h6>\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_044.gif\"><img decoding=\"async\" title=\"Uz\u00e1v\u011br prav\u00e9ho p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" alt=\"Uz\u00e1v\u011br prav\u00e9ho p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_044.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Uz\u00e1v\u011br prav\u00e9ho p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_043.gif\"><img decoding=\"async\" title=\"\u0158e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu\" alt=\"\u0158e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_043.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">\u0158e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_045.gif\"><img loading=\"lazy\" decoding=\"async\" title=\"\u0158e\u010di\u0161t\u011b b\u00e9rce bez patologick\u00e9ho n\u00e1lezu\" alt=\"\u0158e\u010di\u0161t\u011b b\u00e9rce bez patologick\u00e9ho n\u00e1lezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_045.gif\" width=\"200\" height=\"200\" \/><\/a><p class=\"wp-caption-text\">\u0158e\u010di\u0161t\u011b b\u00e9rce bez patologick\u00e9ho n\u00e1lezu<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"<p>Typick\u00fdm zad\u00e1n\u00edm pro c\u00e9vn\u00edho chirurga je stanoven\u00ed diagn\u00f3zy s navr\u017een\u00edm terapeutick\u00e9ho pl\u00e1nu u c\u00e9vn\u00edch onemocn\u011bn\u00ed. Z anamn\u00e9zy a fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed je schopen zhodnotit, kter\u00fd c\u00e9vn\u00ed syst\u00e9m je po\u0161kozen (arteri\u00e1ln\u00ed, \u017eiln\u00ed, lymfatick\u00fd) a zda se jedn\u00e1 o stav akutn\u00ed nebo chronick\u00fd. Z n\u00e1lezu vypl\u00fdv\u00e1 bu\u010f pot\u0159eba akutn\u00edho o\u0161et\u0159en\u00ed stavu, nebo vznik\u00e1 prostor k dal\u0161\u00edmu vy\u0161et\u0159ov\u00e1n\u00ed.Z\u00e1sadn\u00ed je [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":2797,"parent":1868,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1898","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1898","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1898"}],"version-history":[{"count":21,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1898\/revisions"}],"predecessor-version":[{"id":1929,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1898\/revisions\/1929"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1868"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/media\/2797"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1898"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}