{"id":1942,"date":"2013-04-05T15:50:10","date_gmt":"2013-04-05T15:50:10","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1942"},"modified":"2013-06-10T16:57:11","modified_gmt":"2013-06-10T16:57:11","slug":"2-zakladni-postupy-v-cevni-chirurgii","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1942","title":{"rendered":"2 Z\u00e1kladn\u00ed postupy v c\u00e9vn\u00ed chirurgii"},"content":{"rendered":"<h3>2.1 Z\u00e1sady klasick\u00fdch chirurgick\u00fdch postup\u016f v c\u00e9vn\u00ed chirurgii<\/h3>\n<p style=\"text-align: justify;\">V\u011bt\u0161ina nemocn\u00fdch, kte\u0159\u00ed vy\u017eaduj\u00ed c\u00e9vn\u011bchirurgick\u00fd v\u00fdkon, je vy\u0161\u0161\u00edho v\u011bku, jsou polymorbidn\u00ed p\u0159i sv\u00e9m aterosklerotick\u00e9m onemocn\u011bn\u00ed a vy\u017eaduj\u00ed v\u0161eobecn\u00e9 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed a p\u0159\u00edpravu.<\/p>\n<p style=\"text-align: justify;\">Krom\u011b intern\u00edho p\u0159edopera\u010dn\u00edho vy\u0161et\u0159en\u00ed se vy\u0161et\u0159uje ultrazvukem karotick\u00e9 \u0159e\u010di\u0161t\u011b a je nutn\u00e9 kardiologick\u00e9 vy\u0161et\u0159en\u00ed, v\u010detn\u011b srde\u010dn\u00edho echa. P\u0159i patologick\u00e9m n\u00e1lezu na krkavic\u00edch nebo na srdci je t\u0159eba zv\u00e1\u017eit algoritmus v\u00fdkon\u016f \u2013 p\u0159\u00edkladem je n\u00e1lez hemodynamicky v\u00fdznamn\u00e9 sten\u00f3zy vnit\u0159n\u00ed krkavice, kter\u00e1 mus\u00ed b\u00fdt korigov\u00e1na p\u0159ednostn\u011b. Po z\u00edsk\u00e1n\u00ed t\u011bchto podklad\u016f n\u00e1sleduje kontrola l\u00e9ka\u0159em anesteziologicko-resuscita\u010dn\u00edho pracovi\u0161t\u011b, kter\u00fd definitivn\u011b zhodnot\u00ed mo\u017enost opera\u010dn\u00ed z\u00e1t\u011b\u017ee nemocn\u00e9ho (sk\u00f3rovac\u00ed syst\u00e9m ASA) a doporu\u010d\u00ed typ anestezie.<\/p>\n<p style=\"text-align: justify;\">V r\u00e1mci p\u0159edopera\u010dn\u00ed p\u0159\u00edpravy se kontroluj\u00ed tak\u00e9 hodnoty hemokoagulace a zva\u017euje se typ antibiotick\u00e9ho kryt\u00ed opera\u010dn\u00edho v\u00fdkonu. P\u0159i v\u011bt\u0161\u00edch v\u00fdkonech se nemocn\u00fdm objedn\u00e1v\u00e1 krev v krevn\u00ed bance a ve vhodn\u00fdch p\u0159\u00edpadech se zva\u017euje mo\u017enost autotransfuze.<\/p>\n<p style=\"text-align: justify;\">V r\u00e1mci vlastn\u00edho opera\u010dn\u00edho v\u00fdkonu je z\u00e1sadn\u00ed p\u0159\u00edprava opera\u010dn\u00edho pole \u2013 vyholen\u00ed a dezinfekce. P\u0159i ulo\u017een\u00ed nemocn\u00e9ho na opera\u010dn\u00ed st\u016fl je d\u016fle\u017eit\u00e1 jeho spr\u00e1vn\u00e1 poloha pro dan\u00fd v\u00fdkon, prevence dekubit\u016f nebo neurologick\u00fdch poran\u011bn\u00ed (riziko komprese nerv\u016f). Pro c\u00e9vn\u00ed chirurgii existuj\u00ed speci\u00e1ln\u00ed opera\u010dn\u00ed stoly a desky opera\u010dn\u00edch stol\u016f (plovouc\u00ed deska), kter\u00e9 umo\u017e\u0148uj\u00ed peropera\u010dn\u00ed rtg vy\u0161et\u0159en\u00ed.<\/p>\n<p style=\"text-align: justify;\">Nemocn\u00e9mu je zaveden mo\u010dov\u00fd kat\u00e9tr, v z\u00e1vislosti na rozsahu v\u00fdkonu je kanylov\u00e1na centr\u00e1ln\u00ed \u017e\u00edla (nejl\u00e9pe prav\u00e1 vnit\u0159n\u00ed jugul\u00e1rn\u00ed) a k invazivn\u00ed monitoraci krevn\u00edho tlaku se kanyluje arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b (a. radialis).<\/p>\n<p style=\"text-align: justify;\">Tzv. \u201eotev\u0159en\u00e1 c\u00e9vn\u00ed chirurgie\u201c m\u00e1 z\u00e1kladn\u00ed pravidla preparace c\u00e9v, kontroly krv\u00e1cen\u00ed a vyu\u017eit\u00ed c\u00e9vn\u011b-chirurgick\u00fdch technik. Za baz\u00e1ln\u00ed techniky se pova\u017euj\u00ed trombembolektomie, endarterektomie, arteriotomie a uz\u00e1v\u011br arteriotomie, rekonstrukce s pou\u017eit\u00edm bypassu s anastom\u00f3zou typu end-to-side nebo end-to-end.<\/p>\n<p style=\"text-align: justify;\">C\u00e9vn\u011bchirurgick\u00fd v\u00fdkon vy\u017eaduje speci\u00e1ln\u00ed c\u00e9vn\u00ed instrument\u00e1rium (tzv. c\u00e9vn\u00ed s\u00edto), kter\u00e9 obsahuje n\u00e1stroje v tomto oboru pou\u017e\u00edvan\u00e9. Lze je charakterizovat jako jemn\u011bj\u0161\u00ed a precizn\u011bj\u0161\u00ed ne\u017e n\u00e1stroje ur\u010den\u00e9 pro obecnou chirurgii.<\/p>\n<p style=\"text-align: justify;\">V c\u00e9vn\u00ed chirurgii se pou\u017e\u00edv\u00e1 speci\u00e1ln\u00ed \u0161ic\u00ed materi\u00e1l. Ten by m\u011bl b\u00fdt inertn\u00ed k okoln\u00ed tk\u00e1ni, nevyvol\u00e1vat reakce okoln\u00edch tk\u00e1n\u00ed a m\u011bl by b\u00fdt inertn\u00ed v\u016f\u010di infekci. Mus\u00ed b\u00fdt pevn\u00fd, elastick\u00fd, mus\u00ed snadno klouzat a po uzlen\u00ed mus\u00ed b\u00fdt uzly stabiln\u00ed. Uveden\u00e9 po\u017eadavky jsou spl\u0148ov\u00e1ny kombinac\u00ed materi\u00e1lu, struktury a s\u00edly vl\u00e1kna. U p\u0159ev\u00e1\u017en\u00e9 v\u011bt\u0161iny c\u00e9vn\u00edch rekonstrukc\u00ed se pou\u017e\u00edvaj\u00ed neresorbovateln\u00e1 vl\u00e1kna. Nej\u010dast\u011bji se jedn\u00e1 o monofiln\u00ed vl\u00e1kna z polypropylenu nebo polybutylenu. S\u00edla pou\u017e\u00edvan\u00e9ho vl\u00e1kna odpov\u00edd\u00e1 kalibru a kvalit\u011b c\u00e9vy. Vl\u00e1kno je tzv. atraumatick\u00e9 \u2013 je armov\u00e1no do jehly. Velikost jehly odpov\u00edd\u00e1 s\u00edle vl\u00e1kna, jehla m\u016f\u017ee m\u00edt r\u016fznou velikost oblouku a m\u016f\u017ee m\u00edt speci\u00e1ln\u011b tvrzen\u00fd hrot. P\u0159i implantaci ePTFE prot\u00e9z se doporu\u010duje k \u0161it\u00ed atraumatick\u00fd \u0161ic\u00ed materi\u00e1l z ePTFE.<\/p>\n<p style=\"text-align: justify;\">Vlastn\u00ed opera\u010dn\u00ed v\u00fdkon je p\u0159edev\u0161\u00edm preparac\u00ed c\u00e9vn\u00edho svazku. Tento v\u00fdkon vy\u017eaduje dokonal\u00e9 znalosti anatomie a jemnou opera\u010dn\u00ed techniku. C\u00e9va se uvol\u0148uje od okoln\u00ed tk\u00e1n\u011b \u201eve vrstv\u011b\u201c \u2013 v periadventici\u00e1ln\u00ed tk\u00e1ni. Preparace m\u016f\u017ee b\u00fdt zt\u00ed\u017eena z\u00e1n\u011btliv\u00fdmi zm\u011bnami c\u00e9vn\u00ed st\u011bny, hematomy po angiografii nebo vazivov\u00fdmi zm\u011bnami po p\u0159edchoz\u00edch operac\u00edch. I za t\u011bchto okolnost\u00ed je t\u0159eba s c\u00e9vn\u00ed st\u011bnou pracovat maxim\u00e1ln\u011b \u0161etrn\u011b a dle mo\u017enosti chr\u00e1nit odstupuj\u00edc\u00ed v\u011btve (arteri\u00e1ln\u00ed v\u00fdtokov\u00fd trakt). Po preparaci (uvoln\u011bn\u00ed c\u00e9vy od jej\u00edho okol\u00ed) n\u00e1sleduje jej\u00ed \u201ezav\u011b\u0161en\u00ed\u201c na tzv. vessel-loops \u2013 to jsou ploch\u00e9 prou\u017eky (hadi\u010dky) z um\u011bl\u00e9 hmoty, kter\u00e9 po zav\u011b\u0161en\u00ed c\u00e9vy c\u00e9vn\u00ed st\u011bnu netraumatizuj\u00ed. Zav\u011b\u0161en\u00edm c\u00e9vy je zaji\u0161t\u011bna regulace mo\u017en\u00e9ho krv\u00e1cen\u00ed p\u0159ed nalo\u017een\u00edm c\u00e9vn\u00ed svorky.<\/p>\n<p style=\"text-align: justify;\">P\u0159ed uzav\u0159en\u00edm arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b se nemocn\u00fd heparinizuje. Zvykl\u00e1 d\u00e1vka je 75 a\u017e 100 jednotek\/kg a pod\u00e1v\u00e1 se typicky intraven\u00f3zn\u011b asi 5 minut p\u0159ed nalo\u017een\u00edm svorek. Krv\u00e1cen\u00ed z operovan\u00fdch c\u00e9v se zastavuje pomoc\u00ed c\u00e9vn\u00edch svorek, balonkovou okluz\u00ed, c\u00e9vn\u00edmi z\u00e1v\u011bsy a turnikety.Typick\u00e9 uzav\u0159en\u00ed c\u00e9vy se prov\u00e1d\u00ed pomoc\u00ed c\u00e9vn\u00ed svorky, kter\u00e1 se nakl\u00e1d\u00e1 na izolovanou tepnu \u2013 nejl\u00e9pe na zdrav\u00fd \u00fasek arterie. Nalo\u017een\u00ed m\u016f\u017ee b\u00fdt n\u011bkdy komplikovan\u00e9 p\u0159\u00edtomnost\u00ed sklerotick\u00e9ho pl\u00e1tu v arteri\u00e1ln\u00ed st\u011bn\u011b, kdy svorka m\u016f\u017ee pl\u00e1t po\u0161kodit, a ten potom zp\u016fsob\u00ed c\u00e9vn\u00ed uz\u00e1v\u011br po sejmut\u00ed svorky. Mechanismus vzniku uz\u00e1v\u011bru je p\u0159ek\u00e1\u017eka v krevn\u00edm \u0159e\u010di\u0161ti, kterou tvo\u0159\u00ed odchl\u00edpen\u00fd pl\u00e1t a nasedaj\u00edc\u00ed tromb\u00f3za. U v\u00fdrazn\u011b sklerotick\u00e9 art\u00e9rie, kdy pl\u00e1t je cirkul\u00e1rn\u00ed a nalo\u017een\u00ed svorky m\u016f\u017ee zp\u016fsobit jej\u00ed po\u0161kozen\u00ed, lze k uz\u00e1v\u011bru arterie pou\u017e\u00edt okluzi balonkov\u00fdm kat\u00e9trem. Kat\u00e9tr se zav\u00e1d\u00edme arteriotomi\u00ed do \u017e\u00e1dan\u00e9ho \u00faseku arterie a nafouknut\u00edm balonku se arterie uzav\u0159e. Silastikov\u00e9 z\u00e1v\u011bsy c\u00e9v (vessel loops) jsou ur\u010deny ke kontrole z krv\u00e1cen\u00ed st\u0159edn\u00edho a mal\u00e9ho kalibru. Smy\u010dky se dvojit\u011b nalo\u017e\u00ed na arterii a tahem dojde k okluzi arterie. Pneumatick\u00fd turniket se nakl\u00e1d\u00e1 na kon\u010detinu a nafouknut\u00edm na suprasystolick\u00fd tlak se zabr\u00e1n\u00ed toku krve a operuje se v tzv. bezkrevnosti.<\/p>\n<h3>2.2 Z\u00e1sady klasick\u00fdch opera\u010dn\u00edch v\u00fdkon\u016f v c\u00e9vn\u00ed chirurgii<\/h3>\n<p>Za z\u00e1kladn\u00ed chirurgick\u00e9 c\u00e9vn\u00ed v\u00fdkony pova\u017eujeme:<\/p>\n<h6>DESOBLITERACE<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Intralumin\u00e1ln\u00ed \u2013 trombembolektomie<br \/>\n<\/strong>Na embolus, kter\u00fd uzav\u00edr\u00e1 arteri\u00e1ln\u00ed lumen, navazuje \u010dasto tromb\u00f3za, kter\u00e1 se vyskytuje jak pod, tak nad embolem. Proto hovo\u0159\u00edme o trombembolektomii. Dnes obsolentn\u00ed metodou je tzv. p\u0159\u00edm\u00e1 embolektomie, kdy se vypreparovan\u00e1 arterie otev\u0159e p\u0159\u00edmo nad embolem, ten se vyjme a arteriotomie se uzav\u0159e c\u00e9vn\u00edm stehem. Je z\u0159ejm\u00e9, \u017ee metoda vy\u017eaduje p\u0159esnou lokalizaci embolu (UZ nebo ag) a \u017ee preparace m\u016f\u017ee b\u00fdt obt\u00ed\u017en\u00e1, pokud je embolus lokalizov\u00e1n na \u0161patn\u011b p\u0159\u00edstupn\u00e9m \u00faseku arterie (nap\u0159. spole\u010dn\u00e1 ilick\u00e1 arterie). Suver\u00e9nn\u00ed metodou je dnes embolektomie nep\u0159\u00edm\u00e1 (balonkov\u00e1, Fogartyho kat\u00e9trem). Speci\u00e1l-n\u00ed kat\u00e9tr se zav\u00e1d\u00ed z chirurgicky p\u0159\u00edstupn\u00e9ho m\u00edsta(nej\u010dast\u011bji spole\u010dnou femor\u00e1ln\u00ed arteri\u00ed) po arterio-tomii do lumina arterie. Balonkov\u00fd kat\u00e9tr (z histo-rie Fogartyho kat\u00e9tr) je polotuh\u00e1 trubice, na jej\u00edm\u017e jednom konci je balonek, kter\u00fd lze naplnit vzduchem nebo fyziologick\u00fdm roztokem pomoc\u00ed st\u0159\u00edka\u010dky, kter\u00e1 se napoj\u00ed na druh\u00fd konec kat\u00e9tru. Ve svinut\u00e9 (nenapln\u011bn\u00e9 form\u011b) se balonek kat\u00e9tru zavede luminem arterie za p\u0159ek\u00e1\u017eku (embolus) a balonek se napln\u00ed. Kat\u00e9tr se potom p\u0159itahuje do arteriotomie a p\u0159ed sebou hrne embolus, kter\u00fd se potom arteriotomi\u00ed vyjme. Tento postup se m\u016f\u017ee opakovat a \u0159e\u010di\u0161t\u011b se proplachuje fyziologick\u00fdm roztokem s heparinem. Pokud se z arteriotomie stahuje embolus, kter\u00fd byl ulo\u017een sm\u011brem k srdci, je pr\u016fkazem \u00fasp\u011b\u0161n\u00e9 embolektomie obnoven\u00ed arteri\u00e1ln\u00edho p\u0159\u00edtoku. P\u0159i perifern\u00ed embolektomii se prov\u00e1d\u00ed kontroln\u00ed angiografie na opera\u010dn\u00edm s\u00e1le. Krom\u011b balonkov\u00fdch kat\u00e9tr\u016f se pou\u017e\u00edvaj\u00ed pro speci\u00e1ln\u00ed \u00fa\u010dely (trombembolektomie z c\u00e9vn\u00edch prot\u00e9z) kat\u00e9try, kter\u00e9 nemaj\u00ed na konci balonek, ale spir\u00e1ly. Tak jako balonkov\u00e9 kat\u00e9try mohou b\u00fdt r\u016fzn\u00e9ho kalibru, tak i spir\u00e1ly maj\u00ed r\u016fznou kalibraci nebo kvalitu spir\u00e1l (fotogalerie 2a).Nep\u0159\u00edm\u00e1 embolektomie se u v\u011bt\u0161iny nemocn\u00fdch prov\u00e1d\u00ed v lok\u00e1ln\u00ed anestezii. Prob\u00edh\u00e1 antikoagula\u010dn\u00ed l\u00e9\u010dba. Proveden\u00ed embolektomie je v z\u00e1sad\u011b jednoduch\u00fd v\u00fdkon, kter\u00fd v\u0161ak vy\u017eaduje zku\u0161enost. P\u0159i pou\u017eit\u00ed zbyte\u010dn\u011b p\u0159edimenzovan\u00e9ho velk\u00e9ho balonku m\u016f\u017ee p\u0159i embolektomii doj\u00edt k poran\u011bn\u00ed arteri\u00e1ln\u00ed intimy s n\u00e1slednou tromb\u00f3zou arterie.<\/li>\n<li style=\"text-align: justify;\"><strong>Intramur\u00e1ln\u00ed \u2013 endarterektomie a trombendarterektomie<\/strong><br \/>\nP\u0159i t\u00e9to technice se odstra\u0148uje aterosklerotick\u00fd pl\u00e1t, kter\u00fd zu\u017euje nebo uzav\u00edr\u00e1 arteri\u00e1ln\u00ed lumen. Typick\u00fd je tento v\u00fdkon pro hemodynamicky v\u00fdznamn\u00e9 sten\u00f3zy karotick\u00e9 nebo femor\u00e1ln\u00ed vidlice. Endarterektomie se prov\u00e1d\u00ed ve vrstv\u011b, kter\u00e1 je hranic\u00ed mezi vnit\u0159n\u00ed a zevn\u00ed vrstvou arteri\u00e1ln\u00ed medie. Odstra\u0148uje se ztlu\u0161t\u011bl\u00e1 intima a vnit\u0159n\u00ed vrstva medie. Nejb\u011b\u017en\u011bj\u0161\u00ed techniky endarterektomie jsou otev\u0159en\u00e1 a everzn\u00ed endarterektomie. P\u0159i otev\u0159en\u00e9 endarterektomii se po preparaci posti\u017een\u00e9ho \u00faseku arterie pod\u00e9ln\u011b ost\u0159e otev\u0159e a sklerotick\u00fd pl\u00e1t se v popsan\u00e9 vrstv\u011b odstran\u00ed. V luminu arterie by m\u011bla vzniknout rovn\u00e1 plocha. V\u011bt\u0161inou v\u0161ak vzniknou dv\u011b m\u00edsta \u2013 kde endarterektomie v luminu za\u010d\u00edn\u00e1 a kde je ukon\u010dena. Po\u010d\u00e1tek endarterektomie, kter\u00fd je sm\u011brem k srdci, je tzv. po proudu a krevn\u00ed tok j\u00edm nen\u00ed ohro\u017een. Na druh\u00e9m konci mus\u00ed b\u00fdt pl\u00e1t odstran\u011bn tzv. \u201edo ztracena\u201c, to znamen\u00e1, \u017ee mus\u00ed vzniknou plynul\u00fd p\u0159echod mezi endarterektomovan\u00fdm \u00fasekem a d\u00e1le neo\u0161et\u0159enou arteri\u00ed. Pokud by zde vznikla hrana, krevn\u00ed proud by vnit\u0159n\u00ed vrstvu medie odchl\u00edpil a do\u0161lo by k c\u00e9vn\u00edmu uz\u00e1v\u011bru. Pokud by metoda \u201edo ztracena\u201c nebyla provediteln\u00e1, je nutn\u00e9 pl\u00e1t fixovat ke st\u011bn\u011b arterie jednotliv\u00fdmi jemn\u00fdmi stehy. Arteriotomie se uzav\u00edr\u00e1 pokra\u010duj\u00edc\u00edm stehem nebo pomoc\u00ed z\u00e1platy (fotogalerie 2b).<\/li>\n<\/ul>\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 2a: Fogartyho kat\u00e9tr<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\"><strong>Spir\u00e1lov\u00fd Fogartyho kat\u00e9tr<\/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_050.png\"><img decoding=\"async\" title=\"Spir\u00e1lov\u00fd Fogartyho kat\u00e9tr\" alt=\"Spir\u00e1lov\u00fd Fogartyho kat\u00e9tr\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_050.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Spir\u00e1lov\u00fd Fogartyho kat\u00e9tr<\/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_049.png\"><img decoding=\"async\" title=\"Ovl\u00e1d\u00e1n\u00ed kat\u00e9tru\" alt=\"Ovl\u00e1d\u00e1n\u00ed kat\u00e9tru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_049.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ovl\u00e1d\u00e1n\u00ed kat\u00e9tru<\/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_052.png\"><img decoding=\"async\" title=\"Fogartyho kat\u00e9tr, otev\u0159en\u00e1 poloha\" alt=\"Fogartyho kat\u00e9tr, otev\u0159en\u00e1 poloha\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_052.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Fogartyho kat\u00e9tr, otev\u0159en\u00e1 poloha<\/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_051.png\"><img decoding=\"async\" title=\"Fogartyho kat\u00e9tr, zav\u0159en\u00e1 pracovn\u00ed poloha\" alt=\"Fogartyho kat\u00e9tr, zav\u0159en\u00e1 pracovn\u00ed poloha\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_051.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Fogartyho kat\u00e9tr, zav\u0159en\u00e1 pracovn\u00ed poloha<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\u00a0<strong>Trombektomie Fogartyho kat\u00e9trem<\/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_054.png\"><img loading=\"lazy\" decoding=\"async\" title=\"A\" alt=\" A\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_054.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">A<\/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_053.png\"><img loading=\"lazy\" decoding=\"async\" title=\" B\" alt=\" B\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_053.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">B<\/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_058.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"C\" alt=\" C\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_058.jpg\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">C<\/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_055.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"D\" alt=\"D\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_055.jpg\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">D<\/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_059.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"E\" alt=\" E\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_059.jpg\" width=\"200\" height=\"147\" \/><\/a><p class=\"wp-caption-text\">E<\/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_056.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"F\" alt=\"F\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_056.jpg\" width=\"200\" height=\"147\" \/><\/a><p class=\"wp-caption-text\">F<\/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_060.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"G\" alt=\"G\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_060.jpg\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">G<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\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 2b: karotick\u00e1 endarterektomie a ePTFE z\u00e1plata<\/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_062.png\"><img decoding=\"async\" title=\"Arteriotomie karotick\u00e9 vidlice s AS pl\u00e1tem\" alt=\"Arteriotomie karotick\u00e9 vidlice s AS pl\u00e1tem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_062.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Arteriotomie karotick\u00e9 vidlice s AS pl\u00e1tem<\/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_064.png\"><img decoding=\"async\" title=\"Karotick\u00e9 \u0159e\u010di\u0161t\u011b po endarterektomii\" alt=\"Karotick\u00e9 \u0159e\u010di\u0161t\u011b po endarterektomii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_064.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Karotick\u00e9 \u0159e\u010di\u0161t\u011b po endarterektomii<\/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_063.png\"><img loading=\"lazy\" decoding=\"async\" title=\"O\u0161et\u0159en\u00ed karotick\u00e9 arteriotomie \u2013 ePTFE z\u00e1platou\" alt=\"O\u0161et\u0159en\u00ed karotick\u00e9 arteriotomie \u2013 ePTFE z\u00e1platou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_063.png\" width=\"200\" height=\"143\" \/><\/a><p class=\"wp-caption-text\">O\u0161et\u0159en\u00ed karotick\u00e9 arteriotomie \u2013 ePTFE z\u00e1platou<\/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_065.png\"><img decoding=\"async\" title=\"Vyjmut\u00fd AS pl\u00e1t\" alt=\"Vyjmut\u00fd AS pl\u00e1t\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_065.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vyjmut\u00fd AS pl\u00e1t<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">P\u0159i everzn\u00ed technice se arterie p\u0159\u00ed\u010dn\u011b protne, zevn\u00ed vrstva medie s adventici\u00ed jsou evertov\u00e1ny a obna\u017een\u00fd cirkul\u00e1rn\u00ed pl\u00e1t je uvoln\u011bn a odstran\u011bn. Metoda vy\u017eaduje mobilizaci arterie ve v\u011bt\u0161\u00edm rozsahu; za v\u00fdhodn\u00e9 se pova\u017euje, \u017ee reaanastom\u00f3za je hemodynamicky p\u0159\u00edzniv\u011bj\u0161\u00ed ne\u017e uz\u00e1v\u011br pod\u00e9ln\u00e9 arteriotomie.<\/p>\n<h6>C\u00c9VN\u00cd PLASTIKY (DNES M\u00c9N\u011a V\u00ddZNAMN\u00c9, SP\u00cd\u0160E PODP\u016eRN\u00c9 METODY)<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Transpozice, reimplantace<\/strong><br \/>\nTato metoda \u0159e\u0161\u00ed odstupov\u00e9 sten\u00f3zy, nap\u0159. viscer\u00e1ln\u00edch v\u011btv\u00ed aorty nebo ren\u00e1ln\u00edch arteri\u00ed. Arteriese za sten\u00f3zou protne, stenotick\u00fd \u00fasek z\u016fstane p\u0159i aort\u011b a zdrav\u00fd \u00fasek arterie se implantuje koncem ke stran\u011b do zdrav\u00e9ho \u00faseku aorty. Operace b\u00fdv\u00e1 technicky n\u00e1ro\u010dn\u00e1, proto se dnes se tento typ sten\u00f3z \u0159e\u0161\u00ed p\u0159edev\u0161\u00edm endovaskul\u00e1rn\u011b (PTA a stent).<\/li>\n<li style=\"text-align: justify;\"><strong>Intraopera\u010dn\u00ed dilatace<\/strong><br \/>\nChirurgick\u00e1 dilatace ostia v\u00fdtokov\u00e9ho traktu nebosten\u00f3zy ve v\u00fdtokov\u00e9m traktu b\u011b\u017en\u00fdm balonkov\u00fdm kat\u00e9trem je obsolentn\u00ed. Metodu interaopera\u010dn\u00ed angioplastiky p\u0159evzali chirurgov\u00e9 a nebo radiologov\u00e9 a tzv. v\u00edceet\u00e1\u017eov\u00e1 posti\u017een\u00ed se \u0159e\u0161\u00ed v jedn\u00e9 dob\u011b, kdy \u010d\u00e1st v\u00fdkonu prov\u00e1d\u00ed chirurg (nap\u0159. endarte-rektomie femor\u00e1ln\u00ed vidlice) a dal\u0161\u00ed \u010d\u00e1st interven\u010d-n\u00ed radiolog (nap\u0159. angioplastika p\u00e1nevn\u00edho nebofemor\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b).<\/li>\n<li style=\"text-align: justify;\"><strong>C\u00e9vn\u00ed fixace<\/strong><br \/>\nPo v\u00fdkonu na arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti a po obnoven\u00ed krevn\u00edho proudu m\u016f\u017ee doj\u00edt k situaci, \u017ee o\u0161et\u0159en\u00fd \u00fasek bude \u201edlouh\u00fd\u201c s tendenci se zalamovat. Po vytvo\u0159en\u00ed dostate\u010dn\u00e9ho prostoru v r\u00e1n\u011b se arterie fixuje k okol\u00ed, aby vznikl plynul\u00fd oblouk a nedo\u0161lo k zalomen\u00ed a uz\u00e1v\u011bru tepny.<\/li>\n<\/ul>\n<h6>REKONSTRUKCE S C\u00c9VN\u00cd N\u00c1HRADOU<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Roz\u0161i\u0159ovac\u00ed plastiky (patch plastiky)<\/strong><br \/>\nChirurgick\u00e9 v\u00fdkony na arterii jsou spojeny s jej\u00edm pod\u00e9ln\u00fdm otev\u0159en\u00edm (= arteriotomi\u00ed). Uz\u00e1v\u011br arteriotomie se prov\u00e1d\u00ed p\u0159\u00edmou suturou v\u011bt\u0161inou pokra\u010duj\u00edc\u00edm stehem (lze pou\u017e\u00edt i jednotliv\u00e9 stehy). Sutura arterie m\u016f\u017ee b\u00fdt p\u0159\u00ed\u010dinou jej\u00edho z\u00fa\u017een\u00ed. Z\u00fa\u017een\u00edm jsou nejv\u00edce ohro\u017eeny arterie o pr\u016fm\u011bru men\u0161\u00edm ne\u017e 5 mm, arterie se sklerotick\u00fdmi zm\u011bnami st\u011bny nebo arterie, kter\u00e9 maj\u00ed nerovn\u00fd okraj arteriotomie (nap\u0159. po desobliteraci). Aby se zabr\u00e1nilo t\u00e9to komplikaci, uzav\u00edr\u00e1 se arteriotomie v indikovan\u00fdch p\u0159\u00edpadech pomoc\u00ed tzv. z\u00e1platy (patch). Materi\u00e1lem z\u00e1platy b\u00fdv\u00e1 segment autologn\u00ed \u017e\u00edly nebo je z\u00e1plata z ePTFE. Jako autologn\u00ed \u017e\u00edla je nejvhodn\u011bj\u0161\u00ed velk\u00e1 safena. Odeb\u00edr\u00e1 se kr\u00e1tk\u00fd \u00fasek dist\u00e1ln\u00ed safeny z oblasti hlezna. Odebran\u00fd \u00fasek safeny se proplachuje fyziologick\u00fdm roztokem s heparinem a n\u00e1sledn\u011b se pod\u00e9ln\u011b protne. Takto z\u00edskan\u00fd segment safeny se tvarov\u011b uprav\u00ed. Je t\u0159eba vytvo\u0159it z\u00e1platu adekv\u00e1tn\u00ed velikosti ke kalibru arterie. P\u0159\u00edli\u0161 velk\u00e9 z\u00e1platy mohou b\u00fdt p\u0159\u00ed\u010dinou vzniku v\u00fddut\u011b nebo se na jej\u00ed st\u011bn\u011b vytv\u00e1\u0159ej\u00ed tromby. Tato metoda se nap\u0159. pou\u017e\u00edv\u00e1 k uzav\u0159en\u00ed arteriotomie po desobliteraci vnit\u0159n\u00ed karotidy nebo po desobliteraci femor\u00e1ln\u00ed vidlice (fotogalerie 2b).<\/li>\n<li style=\"text-align: justify;\"><strong>Interpozice<\/strong><br \/>\nPrincipem t\u00e9to metody je resekce posti\u017een\u00e9ho arteri\u00e1ln\u00edho \u00faseku a jeho n\u00e1hrada \u017eilou nebo c\u00e9vn\u00ed prot\u00e9zou. Tot\u00e1ln\u00ed resekce a substituce se prov\u00e1d\u00ed p\u0159i onemocn\u011bn\u00edch, kter\u00e1 postihuj\u00ed celou arteri\u00e1ln\u00ed st\u011bnu \u2013 nap\u0159. p\u0159i traumatech nebo n\u00e1dorov\u00fdch infiltrac\u00edch st\u011bny. V c\u00e9vn\u00ed chirurgii je b\u011b\u017en\u011bj\u0161\u00ed parci\u00e1ln\u00ed resekce, kdy posti\u017een\u00fd arteri\u00e1ln\u00ed \u00fasek nen\u00ed odstran\u011bn v cel\u00e9m rozsahu (exstirpov\u00e1n), ale je mo\u017en\u00e9 jej pod\u00e9ln\u011b rozst\u0159ihnout a v m\u00edstech za\u010d\u00e1tku a konce l\u00e9ze arterii p\u0159\u00ed\u010dn\u011b protnout. Protnut\u00ed nemus\u00ed b\u00fdt v cel\u00e9m rozsahu 360 st., ale lze ponechat na zadn\u00ed st\u011bn\u011b arteri\u00e1ln\u00ed m\u016fstek. Ten nebr\u00e1n\u00ed vlo\u017een\u00ed a na\u0161it\u00ed interpon\u00e1tu. Proxim\u00e1ln\u00ed i dist\u00e1ln\u00ed anastom\u00f3za jsou typu end-to-end. Interpozice se nap\u0159. pou\u017e\u00edv\u00e1 p\u0159i n\u00e1hrad\u011b abdomin\u00e1ln\u00ed aorty pro v\u00fddu\u0165 (tub\u00e1rn\u00ed interpozice aorto-aort\u00e1ln\u00ed).<\/li>\n<li style=\"text-align: justify;\"><strong>Bypassov\u00e9 techniky<\/strong><br \/>\nObch\u00e1zej\u00ed p\u0159ek\u00e1\u017eku (uz\u00e1v\u011br) v arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti.K bypassu se dle lokalizace uz\u00e1v\u011bru pou\u017e\u00edv\u00e1 c\u00e9vn\u00ed prot\u00e9za nebo autologn\u00ed \u017e\u00edla. Ob\u011b anastom\u00f3zy jsou typu end-to-side, proxim\u00e1ln\u00ed anastom\u00f3za je lokalizov\u00e1na na arterii nad p\u0159ek\u00e1\u017ekou a dist\u00e1ln\u00ed na arterii pod p\u0159ek\u00e1\u017ekou. Dlouhodob\u00e1 funkce bypassu je z\u00e1visl\u00e1 na \u0159ad\u011b faktor\u016f, nejz\u00e1kladn\u011bj\u0161\u00edm je kvalita v\u00fdtokov\u00e9ho traktu. Typick\u00e9 bypassov\u00e9 operace: aortofemor\u00e1ln\u00ed bypass pomoc\u00ed c\u00e9vn\u00ed prot\u00e9zy a femoropoplite\u00e1ln\u00ed bypass autologn\u00ed \u017eilou. Popsan\u00e1 technika se pou\u017e\u00edv\u00e1 tak\u00e9 k na\u0161it\u00ed arterioven\u00f3zn\u00edch spojek k hemodial\u00fdze (fotogalerie 2c).Po ukon\u010den\u00ed c\u00e9vn\u011b chirurgick\u00e9ho v\u00fdkonu je v\u011bt\u0161inou operovan\u00e1 oblast dr\u00e9novan\u00e1 Redonov\u00fdm drenem. Nemocn\u00fd je dle rozsahu v\u00fdkonu sledov\u00e1n na jednotce intenzivn\u00ed p\u00e9\u010de. Dle typu v\u00fdkonu je l\u00e9\u010den antiagrega\u010dn\u011b nebo antikoagula\u010dn\u011b. N\u00e1sledn\u00e1 poopera\u010dn\u00ed kontrola (b\u011bhem hospitalizace) se prov\u00e1d\u00ed fyzik\u00e1ln\u00edm vy\u0161et\u0159en\u00edm, barevnou duplexn\u00ed sonografi\u00ed nebo v p\u0159\u00edpad\u011b nejasn\u00fdch n\u00e1lez\u016f n\u011bkterou z angiografick\u00fdch modalit.<\/li>\n<\/ul>\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 2c: bypass ePTFE prot\u00e9zou<\/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_069.png\"><img decoding=\"async\" title=\"Podko\u017en\u011b ulo\u017een\u00e1 ePTFE prot\u00e9za k hemodial\u00fdze\" alt=\"Podko\u017en\u011b ulo\u017een\u00e1 ePTFE prot\u00e9za k hemodial\u00fdze\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_069.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Podko\u017en\u011b ulo\u017een\u00e1 ePTFE prot\u00e9za k hemodial\u00fdze<\/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_068.png\"><img decoding=\"async\" title=\"Anastom\u00f3zy mezi prot\u00e9zou a autologn\u00edm \u0159e\u010di\u0161t\u011bm\" alt=\"Anastom\u00f3zy mezi prot\u00e9zou a autologn\u00edm \u0159e\u010di\u0161t\u011bm\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_068.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Anastom\u00f3zy mezi prot\u00e9zou a autologn\u00edm \u0159e\u010di\u0161t\u011bm<\/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_071.png\"><img decoding=\"async\" title=\"Anastom\u00f3za II\" alt=\"Anastom\u00f3za II\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_071.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Anastom\u00f3za II<\/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_070.png\"><img decoding=\"async\" title=\"Anastom\u00f3za I\" alt=\"Anastom\u00f3za I\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_070.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Anastom\u00f3za I<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"<p>2.1 Z\u00e1sady klasick\u00fdch chirurgick\u00fdch postup\u016f v c\u00e9vn\u00ed chirurgii V\u011bt\u0161ina nemocn\u00fdch, kte\u0159\u00ed vy\u017eaduj\u00ed c\u00e9vn\u011bchirurgick\u00fd v\u00fdkon, je vy\u0161\u0161\u00edho v\u011bku, jsou polymorbidn\u00ed p\u0159i sv\u00e9m aterosklerotick\u00e9m onemocn\u011bn\u00ed a vy\u017eaduj\u00ed v\u0161eobecn\u00e9 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed a p\u0159\u00edpravu. Krom\u011b intern\u00edho p\u0159edopera\u010dn\u00edho vy\u0161et\u0159en\u00ed se vy\u0161et\u0159uje ultrazvukem karotick\u00e9 \u0159e\u010di\u0161t\u011b a je nutn\u00e9 kardiologick\u00e9 vy\u0161et\u0159en\u00ed, v\u010detn\u011b srde\u010dn\u00edho echa. P\u0159i patologick\u00e9m n\u00e1lezu na krkavic\u00edch nebo na srdci [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":10,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1942","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1942","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=1942"}],"version-history":[{"count":12,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1942\/revisions"}],"predecessor-version":[{"id":3810,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1942\/revisions\/3810"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1868"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1942"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}