{"id":2031,"date":"2013-04-05T19:23:32","date_gmt":"2013-04-05T19:23:32","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2031"},"modified":"2013-06-11T11:52:30","modified_gmt":"2013-06-11T11:52:30","slug":"4-specialni-problematika-arterialnich-onemocneni","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2031","title":{"rendered":"4 Speci\u00e1ln\u00ed problematika arteri\u00e1ln\u00edch onemocn\u011bn\u00ed"},"content":{"rendered":"<h3>4.1 Akutn\u00ed kon\u010detinov\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br (embolizace a tromb\u00f3za)<\/h3>\n<p style=\"text-align: justify;\">\u00a0Jedn\u00e1 se n\u00e1hle vzniklou poruchu prokrven\u00ed (ischemii) kon\u010detiny, p\u0159i kter\u00e9 je bezprost\u0159edn\u011b ohro\u017eena viabilita kon\u010detiny. Nej\u010dast\u011bji b\u00fdv\u00e1 posti\u017eena jedna doln\u00ed kon\u010detina (85%), m\u00e9n\u011b \u010dasto jsou posti\u017eeny ob\u011b doln\u00ed kon\u010detiny nebo horn\u00ed kon\u010detina. Ischemie je zpo\u010d\u00e1tku reverzibiln\u00ed, pokud nen\u00ed o\u0161et\u0159ena dojde k ireverzibiln\u00edm zm\u011bn\u00e1m a gangr\u00e9n\u011b tk\u00e1n\u00ed. Stupe\u0148 po\u0161kozen\u00ed tk\u00e1n\u00ed odpov\u00edd\u00e1 jejich schopnosti tolerovat ischemii. K\u016f\u017ee toleruje ischemii do 12 hodin, svaly6\u20138 hodiny, nejcitliv\u011bj\u0161\u00ed je nervov\u00e1 tk\u00e1\u0148 s toleranc\u00ed 2\u20134 hodiny. Pokud je p\u0159ekro\u010dena hranice tolerance,vznikaj\u00ed trval\u00e9 defekty, hroz\u00ed riziko ztr\u00e1ty kon\u010detiny nebo i smrti (sepse). V\u00fdsledky l\u00e9\u010dby jsou p\u0159\u00edmo z\u00e1visl\u00e9 na \u010dasov\u00e9m intervalu mezi vznikem pot\u00ed\u017e\u00ed a n\u00e1stupem l\u00e9\u010dby. Akutn\u00ed c\u00e9vn\u00ed uz\u00e1v\u011br je n\u00e1hl\u00e1 p\u0159\u00edhoda, kter\u00e9 vy\u017eaduje okam\u017eit\u00e9 o\u0161et\u0159en\u00ed.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou akutn\u00edho uz\u00e1v\u011bru kon\u010detinov\u00fdch tepen je trombembolizace (70%), m\u00e9n\u011b \u010dasto se jedn\u00e1 o akutn\u00ed lok\u00e1ln\u00ed tromb\u00f3zy (30%).<\/li>\n<li style=\"text-align: justify;\">M\u00edstem vzniku a zdrojem trombembol\u016f je srdce (85%) \u2013 nej\u010dast\u011bji p\u0159i fibrilaci s\u00edn\u00ed (70%), stavech po IM s poruchou kinetiky lev\u00e9 komory, p\u0159i chronick\u00e9 kardi\u00e1ln\u00ed dekompenzaci, p\u0159i chlop\u0148ov\u00fdch vegetac\u00edch. Dal\u0161\u00ed mo\u017en\u00e9 zdroje: dilata\u010dn\u00ed formaateroskler\u00f3zy, aneuryzmata, myxom (histologieemboliza\u010dn\u00edho materi\u00e1lu).<\/li>\n<li style=\"text-align: justify;\">Nekardi\u00e1ln\u00ed zdroje embol\u016f se vyskytuj\u00ed v 10\u201320%, zdrojem jsou v\u00fddut\u011b aortoilick\u00e9 oblasti a v\u00fddut\u011b fe-moropoplite\u00e1ln\u00ed oblasti, p\u0159\u00ed\u010dinou akutn\u00edho uz\u00e1v\u011bru mohou b\u00fdt kompresn\u00ed syndromy, tumory a paradoxn\u00ed embolizace p\u0159i otev\u0159en\u00e9m foramen ovale.U 5\u201310% nemocn\u00fdch se zdroj embolizace nepoda\u0159\u00ed prok\u00e1zat.<\/li>\n<li style=\"text-align: justify;\">Nar\u016fst\u00e1 pod\u00edl akutn\u00edch lok\u00e1ln\u00edch tromb\u00f3z, kter\u00e9 vyvol\u00e1vaj\u00ed akutn\u00ed ischemii. Etiologicky je p\u0159\u00ed\u010dinou v\u011bt\u0161inou ateroskler\u00f3za, m\u00e9n\u011b \u010dasto disekce, traumata, vaskulitidy, pol\u00e9kov\u00e9 stavy a paraneoplastick\u00e9 procesy. Vznik akutn\u00ed tromb\u00f3zy potencuj\u00ed hyperkoagula\u010dn\u00ed stavy, hypovol\u00e9mie a srde\u010dn\u00ed nedostate\u010dnost (fotogalerie 4a).<\/li>\n<li style=\"text-align: justify;\">Emboly kardi\u00e1ln\u00edho p\u016fvodu se zachyt\u00e1vaj\u00ed nej\u010dast\u011bji v m\u00edstech v\u011btven\u00ed tepen, aterosklerotick\u00e9 emboly perifern\u011bji a\u017e akr\u00e1ln\u011b.<\/li>\n<li style=\"text-align: justify;\">D\u016fsledkem embolie je perifern\u00ed ischemie, jej\u00ed\u017e rozsah je d\u00e1n lokalizac\u00ed embolu, pod embolem vznik\u00e1 vasospazmus, nad embolem krev stagnuje \u2013 vznik\u00e1 apozi\u010dn\u00ed tromb\u00f3za.<\/li>\n<li style=\"text-align: justify;\">Klinick\u00e9 projevy = 6 P\n<ul style=\"text-align: justify;\">\n<li>pain \u2013 bolest,<\/li>\n<li>paleness, pallor \u2013 bledost,<\/li>\n<li>paresthesia, paralysis \u2013 senzoricko-motorick\u00e1 porucha,<\/li>\n<li>pulselessnes \u2013 vymizel\u00e1 pulzace,<\/li>\n<li>prostration \u2013 schv\u00e1cenost nemocn\u00e9ho a\u017e \u0161okov\u00fd stav.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Rozsah ischemie vypl\u00fdv\u00e1 ze zbytkov\u00e9 perfuze, kter\u00e1 je d\u00e1na lokalizac\u00ed a velikost\u00ed uz\u00e1v\u011bru a ev. existenc\u00ed kolater\u00e1ln\u00edho ob\u011bhu. Akutn\u00ed arteri\u00e1ln\u00ed tromb\u00f3zau nemocn\u00e9ho s chronickou ischemickou chorobou doln\u00edch kon\u010detin a s kolater\u00e1ln\u00edm ob\u011bhem m\u00e1 mnohem m\u00edrn\u011bj\u0161\u00ed pr\u016fb\u011bh ne\u017e u nemocn\u00e9ho s embolick\u00fdm uz\u00e1v\u011brem a s chyb\u011bj\u00edc\u00edm kolater\u00e1ln\u00edm ob\u011bhem.<\/li>\n<li style=\"text-align: justify;\">Fyzik\u00e1ln\u00ed n\u00e1lez je z\u0159ejm\u00fd: z\u00e1sadn\u00ed je v\u017edy srovn\u00e1vat n\u00e1lez na kon\u010detin\u00e1ch, nap\u0159. srovn\u00e1n\u00ed pulzac\u00ed na kon\u010detin\u00e1ch, dopln\u011bn\u00ed anamn\u00e9zy (nejsou zn\u00e1mky chronick\u00e9 kon\u010detinov\u00e9 ischemie). Stupe\u0148 ischemie vypl\u00fdv\u00e1 z poruchy motoriky a c\u00edtivosti. P\u0159ijejich ztr\u00e1t\u011b lze p\u0159edpokl\u00e1dat kompletn\u00ed ischemii.<\/li>\n<li style=\"text-align: justify;\">Dopl\u0148uj\u00edc\u00ed p\u0159\u00edstrojov\u00e9 vy\u0161et\u0159en\u00ed nen\u00ed v\u011bt\u0161inou indikov\u00e1no, nemocn\u00fd vy\u0161et\u0159ov\u00e1n\u00edm \u201eztr\u00e1c\u00ed \u010das\u201c \u2013 to se t\u00fdk\u00e1 p\u0159edev\u0161\u00edm z\u0159ejm\u00e9 embolizace. U akutn\u00edchtromb\u00f3z m\u00e1 v\u00fdznam UZ vy\u0161et\u0159en\u00ed pro zhodnocen\u00edpr\u016ftoku, ale tak\u00e9 k vylou\u010den\u00ed nebo potvrzen\u00ed aneuryzmatu (nap\u0159. uz\u00e1v\u011br p\u0159i aneuryzmatu poplite\u00e1l<\/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 4a: akutn\u00ed arteri\u00e1ln\u00ed tromb\u00f3za<\/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_113.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v cel\u00e9m rozsahu\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v cel\u00e9m rozsahu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_113.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v cel\u00e9m rozsahu<\/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_112.jpg\"><img decoding=\"async\" title=\"CT ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" alt=\"CT ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_112.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b<\/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_115.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu I\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu I\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_115.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu I<\/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_114.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu II\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu II\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_114.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu II<\/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_118.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu III\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu III\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_118.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu III<\/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_117.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu IV\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu IV\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_117.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu IV<\/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_120.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu V\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu V\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_120.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu V<\/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_119.jpg\"><img decoding=\"async\" title=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu VI\" alt=\"CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu VI\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_119.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">CT ag arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b v detailu VI<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\">\u00a0Z\u00e1kladn\u00edm prvn\u00edm krokem v l\u00e9\u010db\u011b je bolusov\u00e9 pod\u00e1n\u00ed heparinu i. v. \u2013 v\u011bt\u0161inou 10 000 jednotek pro zabr\u00e1n\u011bn\u00ed apozi\u010dn\u00ed tromb\u00f3zy, ev. dal\u0161\u00ed embolizace. Kon\u010detina je ulo\u017eena do vatov\u00e9ho obvazu a spu\u0161t\u011bna. Je pod\u00e1na analgetick\u00e1 terapie, nikoliv v\u0161ak intramuskul\u00e1rn\u011b p\u0159i p\u0159edpokladu trombolytick\u00e9 l\u00e9\u010dby.<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00e1 terapie: trombembolektomie nep\u0159\u00edm\u00e1 fogartyho kat\u00e9trem nebo trombembolektomie p\u0159\u00edm\u00e1 p\u0159i embolizaci.<\/li>\n<li style=\"text-align: justify;\">Trombendarterektomie nebo bypass u akutn\u00edch arteri\u00e1ln\u00edch tromb\u00f3z.<\/li>\n<li style=\"text-align: justify;\">Trombolytick\u00e1 l\u00e9\u010dba: kontinu\u00e1ln\u00ed lok\u00e1ln\u00ed trombol\u00fdza nebo infiltra\u010dn\u00ed trombol\u00fdza urokin\u00e1zou nebo aktiv\u00e1tory plazminogenu (rtPA).<\/li>\n<li style=\"text-align: justify;\">Kat\u00e9trov\u00e9 mechanick\u00e9 trombembolektomie: perkut\u00e1nn\u00ed aspira\u010dn\u00ed trombembolektomie, mechanick\u00e1 kat\u00e9trov\u00e1 fragmentace (rotarex), hydrodynamick\u00e9 kat\u00e9rov\u00e9 syst\u00e9my (angio-jet). Tyto perkut\u00e1nn\u00ed metody lze navz\u00e1jem kombinovat \u2013 v\u010detn\u011b l\u00fdzy a angioplastiky. Jejich v\u00fdhodou je mo\u017enost o\u0161et\u0159en\u00ed arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b b\u00e9rce a nohy.Z uveden\u00fdch poznatk\u016f je z\u0159ejm\u00e9, \u017ee terapeutick\u00fd model m\u016f\u017ee b\u00fdt u ka\u017ed\u00e9ho nemocn\u00e9ho individu\u00e1ln\u00ed a r\u016fzn\u011b modifikov\u00e1n. Z\u00e1vis\u00ed na vybaven\u00ed a zku\u0161enosti c\u00e9vn\u00edho centra, kterou metodu nebo kombinaci metod zvol\u00ed. Znalost a dostupnost uveden\u00fdch metod umo\u017e\u0148uje p\u0159i selh\u00e1n\u00ed prvn\u00ed zvolen\u00e9 metody pou\u017e\u00edt jin\u00fd postup (opera\u010dn\u00ed v\u00fdkon a navazuj\u00edc\u00ed l\u00fdza). U akutn\u00edch emboliza\u010dn\u00edch c\u00e9vn\u00edch uz\u00e1v\u011br\u016f s nevy-vinut\u00fdm kolater\u00e1ln\u00edm ob\u011bhem je nutnost okam\u017eit\u00e9 intervence. \u010casto se zd\u016fraz\u0148uje \u010dasov\u00fd interval do operace 6 hodin. Uveden\u00fd interval sice p\u0159edstavuje krit\u00e9rium \u00fasp\u011b\u0161n\u00e9ho v\u00fdkonu, je v\u0161ak individu\u00e1ln\u00ed a je v\u017edy nutn\u00e9 vy\u0161et\u0159en\u00ed lok\u00e1ln\u00edho n\u00e1lezu. Ten ur\u010duje mo\u017en\u00fd \u00fasp\u011bch opera\u010dn\u00edho v\u00fdkonu, a i tzv. pozdn\u00ed embolektomie m\u016f\u017ee m\u00edt pro nemocn\u00e9ho z\u00e1sadn\u00ed v\u00fdznam. Kon\u010detina m\u016f\u017ee b\u00fdt po embolektomii v\u00fdrazn\u011b funk\u010dn\u011b po\u0161kozena, ale v\u011bt\u0161inou spl\u0148uje funkci l\u00e9pe ne\u017e prot\u00e9za po amputaci.V z\u00e1vislosti na d\u00e9lce a rozsahu ischemie je t\u0159eba po \u00fasp\u011b\u0161n\u00e9 revaskularizaci po\u010d\u00edtat se vznikem reperf\u00fazn\u00edho syndromu (kompartment sy). Revaskularizovanou kon\u010detinu je t\u0159eba klinicky kontrolovat (tlak v m\u011bkk\u00fdch tk\u00e1n\u00edch b\u00e9rce, p\u0159edlokt\u00ed) a p\u0159i vzniku reperf\u00fazn\u00edho syndromu prov\u00e9st fasciotomii. Sou\u010dasn\u00e1 infuzn\u00ed terapie podporuje diur\u00e9zu k vylou\u010den\u00ed myoglobinu. Pokro\u010dil\u00e1 stadia ischemie vedou k po\u0161kozen\u00ed nejen tk\u00e1n\u00ed kon\u010detiny, ale m\u016f\u017ee doj\u00edt k po\u0161kozen\u00ed ledvin p\u0159i myoglobinurii, k hypovol\u00e9mii a k poruch\u00e1m srde\u010dn\u00edho rytmu p\u0159i hyperkal\u00e9mii a acid\u00f3ze. D\u016fsledkem m\u016f\u017ee b\u00fdt multiorg\u00e1nov\u00e9 selh\u00e1n\u00ed. Z t\u011bchto d\u016fvod\u016f vy\u017eaduj\u00ed nemocn\u00ed intenzivn\u00ed p\u00e9\u010di. P\u0159i nep\u0159\u00edzniv\u00e9m poopera\u010dn\u00edm pr\u016fb\u011bhu, kdy po \u00fasp\u011b\u0161n\u00e9 (ale pozdn\u00ed) revaskularizaci dojde k ohro\u017een\u00ed vit\u00e1ln\u00edch funkc\u00ed, je indikov\u00e1na vysok\u00e1 amputace pro ohro\u017een\u00ed nemocn\u00e9ho toxick\u00fdmi metabolity z ischemick\u00fdch tk\u00e1n\u00ed.Po vy\u0159e\u0161en\u00ed akutn\u00edho stavu je t\u0159eba nal\u00e9zt zdroj embolizace \u2013 p\u0159i arytmi\u00edch je indikov\u00e1na antikoagula\u010dn\u00ed terapie. Pro zlep\u0161en\u00ed pr\u016fchodnosti o\u0161et\u0159en\u00e9ho arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b je indikov\u00e1na antigrega\u010dn\u00ed nebo v n\u011bkter\u00fdch p\u0159\u00edpadech antikoagula\u010dn\u00ed terapie.<\/li>\n<\/ul>\n<h3>4.2 Chronick\u00e9 kon\u010detinov\u00e9 c\u00e9vn\u00ed uz\u00e1v\u011bry<\/h3>\n<h6>AORTA A P\u00c1NEVN\u00cd \u0158E\u010cI\u0160T\u011a<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>\u00davod<\/strong><br \/>\nAort\u00e1ln\u00ed a p\u00e1nevn\u00ed vidlice p\u0159edstavuj\u00ed predilek\u010dn\u00ed m\u00edsto manifestace ateroskler\u00f3zy, p\u0159i\u010dem\u017e lokalizace onemocn\u011bn\u00ed ovliv\u0148uje nejenom prokrven\u00ed p\u00e1nve,ale sou\u010dasn\u011b doln\u00edch kon\u010detin. Sou\u010dasn\u00fd pohled na l\u00e9\u010dbu projev\u016f ateroskler\u00f3zy v t\u00e9to oblasti se zm\u011bnil; nen\u00ed kladen d\u016fraz jen na dlouhodob\u00e9 v\u00fdsledky jako na z\u00e1kladn\u00ed krit\u00e9rium l\u00e9\u010dby, ale o\u010dek\u00e1van\u00fd v\u00fdsledek je korigov\u00e1n v\u011bkem a celkov\u00fdm stavem nemocn\u00e9ho. U star\u00fdch a polymorbidn\u00edch nemocn\u00fdch s krat\u0161\u00ed p\u0159edpokl\u00e1danou d\u00e9lkou \u017eivota se ustupuje od radikality rozs\u00e1hl\u00fdch rekonstrukc\u00ed ve prosp\u011bch jednodu\u0161\u0161\u00edch nap\u0159. endovaskul\u00e1rn\u00edch v\u00fdkon\u016f, kter\u00e9 jsou spojeny s men\u0161\u00ed invazivitou. Morfologicky se degenerativn\u00ed aterosklerotick\u00e9 zm\u011bny v \u0159e\u010di\u0161ti b\u0159i\u0161n\u00ed aorty nebo v p\u00e1nevn\u00edm \u0159e\u010di\u0161ti projevuj\u00ed nejen formu stenozuj\u00edc\u00ed a uz\u00e1v\u011brovou, aletak\u00e9 dilata\u010dn\u00ed a elonga\u010dn\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>Klinick\u00fd obraz<\/strong><br \/>\nP\u0159i posti\u017een\u00ed aorty a p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b aterosklerotick\u00fdm procesem bez posti\u017een\u00ed perifern\u011bj\u0161\u00edch et\u00e1\u017e\u00ed vedou hemodynamicky v\u00fdznamn\u00e9 zm\u011bny k projev\u016fm stehenn\u00edch klaudikac\u00ed. P\u0159i posti\u017een\u00ed vnit\u0159n\u00edch ilick\u00fdch arteri\u00ed vznikaj\u00ed klaudikace h\u00fd\u017e\u010fov\u00e9. Pokud jsou sou\u010dasn\u011b klidov\u00e9 bolesti nebo nekr\u00f3zy na periferii kon\u010detiny (stadium F III a IV) je t\u0159eba p\u0159edpokl\u00e1dat sou\u010dasn\u00e9 posti\u017een\u00ed \u0159e\u010di\u0161t\u011b stehna a b\u00e9rce. Vyj\u00edmkou je sou\u010dasn\u00fd uz\u00e1v\u011br obou vnit\u0159n\u00edch ilick\u00fdch arteri\u00ed, kter\u00fd vede k nekr\u00f3ze glute\u00e1ln\u00edch sval\u016f a v\u011bt\u0161inou ke smrti nemocn\u00e9ho. Sn\u00ed\u017een\u00ed perfuze \u0159e\u010di\u0161t\u011bm vnit\u0159n\u00edch ilick\u00fdch arteri\u00ed vede k erektiln\u00ed dysfunkci. P\u0159edev\u0161\u00edm lev\u00e1 vnit\u0159n\u00ed ilick\u00e1 arterie m\u00e1 v\u00fdznam p\u0159i vzniku kolater\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b p\u0159i ischemii st\u0159evn\u00edho \u0159e\u010di\u0161t\u011b. Chronick\u00e9 uz\u00e1v\u011bry truncus coeliacus, horn\u00ed a doln\u00ed mesenterick\u00e9 arterie mohou b\u00fdt levou vnit\u0159n\u00ed ilikou kompenzov\u00e1ny.<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<\/strong><br \/>\nOblig\u00e1tn\u011b se jedn\u00e1 o anamn\u00e9zu (klaudikace), podrobn\u00e9 klinick\u00e9 a p\u0159\u00edstrojov\u00e9 vy\u0161et\u0159en\u00ed se zam\u011b\u0159en\u00edm na:<\/p>\n<ul>\n<li style=\"text-align: justify;\">Celkov\u00e9 obecn\u00e9 vy\u0161et\u0159en\u00ed nemocn\u00e9ho, zvl\u00e1\u0161t\u011b vy\u0161et\u0159en\u00ed pulzu na femor\u00e1ln\u00ed arterii (absencepulzu), p\u0159i oboustrann\u00e9m uz\u00e1v\u011bru s absenc\u00ed pulzace se jedn\u00e1 o tzv. Lerich\u016fv syndrom.<\/li>\n<li style=\"text-align: justify;\">UZ vy\u0161et\u0159en\u00ed, barevn\u00e1 duplexn\u00ed sonografie\u00a0 \u2013 zhodnot\u00ed lokalizaci a hemodynamickou v\u00fdznamnost sten\u00f3zy, pop\u00ed\u0161e uz\u00e1v\u011br.<\/li>\n<li style=\"text-align: justify;\">P\u0159i zva\u017eov\u00e1n\u00ed chirurgick\u00e9ho nebo endovaskul\u00e1rn\u00edho v\u00fdkonu n\u00e1sleduj\u00ed vy\u0161et\u0159en\u00ed cestou NMR agnebo CT ag. NMR ag je dnes nejv\u00edce vyu\u017e\u00edvan\u00e1,kontraindikac\u00ed jsou PM a kovov\u00fd materi\u00e1l v t\u011ble nemocn\u00e9ho (odrazy). CT ag zat\u011b\u017euje nemocn\u00e9-ho expozic\u00ed rtg z\u00e1\u0159en\u00ed a pod\u00e1n\u00edm jodov\u00e9 kon-trastn\u00ed l\u00e1tky.<\/li>\n<li style=\"text-align: justify;\">Digit\u00e1ln\u00ed subtrak\u010dn\u00ed angiografie p\u0159edstavuje za cenu invazivity nejkvalitn\u011bj\u0161\u00ed zobrazovac\u00ed metodu. V oblasti diagnostiky je ur\u010dena jen prospeci\u00e1ln\u00ed p\u0159\u00edpady nejasn\u00fdch n\u00e1lez\u016f. Jej\u00ed v\u00fdznam je dnes p\u0159edev\u0161\u00edm v endovaskul\u00e1rn\u00ed l\u00e9\u010db\u011b.<\/li>\n<li style=\"text-align: justify;\">U nemocn\u00fdch s ledvinnou nedostate\u010dnost\u00ed nebo s alergi\u00ed na kontrastn\u00ed l\u00e1tky je mo\u017en\u00e1 CO2 angiografie. Tato metoda umo\u017e\u0148uje tak\u00e9 translumin\u00e1ln\u00ed intervence v p\u00e1nevn\u00edm \u0159e\u010di\u0161ti.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Indikace k v\u00fdkonu Vypl\u00fdv\u00e1 z klinick\u00e9ho n\u00e1lezu, pot\u00ed\u017e\u00ed nemocn\u00e9ho, komorbidit a patologick\u00e9ho n\u00e1lezu na c\u00e9vn\u00edm \u0159e\u010di\u0161ti.\n<ul>\n<li style=\"text-align: justify;\">Ve stadiu IIa (klaudika\u010dn\u00ed interval nad 200 m) se doporu\u010duje ovlivnit rizikov\u00e9 faktory (metabolick\u00e1 onemocn\u011bn\u00ed) a antiagrega\u010dn\u00ed terapie.<\/li>\n<li style=\"text-align: justify;\">Stadium IIb (klaudika\u010dn\u00ed interval pod 200 m) je relativn\u00ed indikac\u00ed k intervenci. Indikace z\u00e1vis\u00ed na subjektivn\u00edm zhodnocen\u00ed pot\u00ed\u017e\u00ed nemocn\u00e9ho, komorbidit\u00e1ch a c\u00e9vn\u00edm n\u00e1lezu.<\/li>\n<li style=\"text-align: justify;\">Stadium III (klidov\u00e9 bolesti) a IV (tk\u00e1\u0148ov\u00e9 defekty) jsou absolutn\u00ed indikac\u00ed k v\u00fdkonu. Je t\u0159eba pe\u010dliv\u011b zhodnotit stav stehenn\u00edho a b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010dba<\/strong><br \/>\nGuidelines pro terapii ischemick\u00e9 choroby doln\u00edch kon\u010detin p\u0159edstavuje TASC-II-klasifikace. Jej\u00ed podrobn\u00e1 doporu\u010den\u00ed jsou mimo rozsah t\u00e9to publikace.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Konzervativn\u00ed terapie je v\u017edy indikov\u00e1na jako prvn\u00ed, pokud se jedn\u00e1 o stadium F II. Jej\u00ed \u00fasp\u011bch je v\u0161ak limitov\u00e1n pom\u011brn\u011b mal\u00fdmi mo\u017enostmi vzniku kolater\u00e1ln\u00edho ob\u011bhu, kter\u00fd by obe\u0161el uz\u00e1v\u011br na \u00farovni aorta \u2013 arteria iliaca communis.<\/li>\n<li style=\"text-align: justify;\">Endovaskul\u00e1rn\u00ed l\u00e9\u010dba je ur\u010dena p\u0159edev\u0161\u00edm pro sten\u00f3zy infraren\u00e1ln\u00ed aorty a p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b, d\u00e1le pro kr\u00e1tk\u00e9 uz\u00e1v\u011bry p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b. Jedn\u00e1 se o typick\u00fd trend, kter\u00fd podporuje endovaskul\u00e1rn\u00ed terapii u star\u00fdch a rizikov\u00fdch nemocn\u00fdch. Endovaskul\u00e1rn\u00ed l\u00e9\u010dba je m\u00e9n\u011b zat\u00ed\u017e\u00ed, co\u017e se pova\u017euje za v\u011bt\u0161\u00ed benefit ne\u017e n\u00e1ro\u010dn\u00fd chirurgick\u00fd v\u00fdkon s del\u0161\u00ed funkc\u00ed. Stenty se po angioplastice pou\u017e\u00edvaj\u00ed selektivn\u011b, nikoliv pau\u0161\u00e1ln\u011b. Selektivn\u00ed je tak\u00e9 indikace pro zaveden\u00ed stentgraftu v t\u00e9to indikaci.<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00e1 \u2013 opera\u010dn\u00ed l\u00e9\u010dba je ur\u010dena pro nemocn\u00e9 s difuzn\u00edm posti\u017een\u00edm (mnoho\u010detn\u00e9 sten\u00f3zy a uz\u00e1v\u011bry) p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b, kdy je nebo m\u016f\u017ee b\u00fdt posti\u017eeno i aort\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b. Aterosklerotick\u00fdm procesem b\u00fdv\u00e1 posti\u017eeno tak\u00e9 \u0159e\u010di\u0161t\u011b spole\u010dn\u00e9 femor\u00e1ln\u00ed arterie.<\/li>\n<li style=\"text-align: justify;\">Anatomick\u00e9 rekonstrukce jsou ur\u010deny pro uz\u00e1v\u011bry infraren\u00e1ln\u00ed aorty bez nebo s posti\u017een\u00edm p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b. K n\u00e1hrad\u011b se pou\u017e\u00edv\u00e1 tub\u00e1rn\u00ed nebo Y prot\u00e9za. Proxim\u00e1ln\u00ed anastom\u00f3za se na\u0161\u00edv\u00e1 na infraren\u00e1ln\u00ed (t\u011bsn\u011b pod odstupem ren\u00e1ln\u00edch arteri\u00ed) \u00fasek aorty, kde b\u00fdvaj\u00ed nejmen\u0161\u00ed sklerotick\u00e9 zm\u011bny. \u010casto i v t\u00e9to lokalizaci mus\u00ed b\u00fdt aorta endarterektomov\u00e1na. Dist\u00e1ln\u00ed \u00fasek bypassu je jedno nebo oboustrann\u00fd a jako v\u00fdtokov\u00fd trakt se pou\u017e\u00edv\u00e1 zevn\u00ed p\u00e1nevn\u00ed arterie, spole\u010dn\u00e1 femor\u00e1ln\u00ed arterie nebo hlubok\u00e1 stehenn\u00ed tepna. Z hlediska rizika infekce je v\u017edy vhodn\u011bj\u0161\u00ed anastom\u00f3za nad t\u0159\u00edseln\u00fdm vazem.<\/li>\n<li style=\"text-align: justify;\">Extranatomick\u00e9 rekonstrukce jsou ur\u010deny pro nemocn\u00e9, kdy endovaskul\u00e1rn\u00ed metody nejsou vhodn\u00e9 a anatomick\u00e1 rekonstrukce by byla spojena v vysok\u00fdm opera\u010dn\u00edm rizikem. Tento cross-over bypass p\u0159iv\u00e1d\u00ed krev ze strany s dobr\u00fdm p\u0159\u00edtokem z p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b na kontralater\u00e1ln\u00ed stranu v\u011bt\u0161inou do femor\u00e1ln\u00ed vidlice (S bypass) nebo z femor\u00e1ln\u00ed arterie (C bypass). Ve vyj\u00edme\u010dn\u00fdch p\u0159\u00edpadech je u nemocn\u00fdch s kritickou ischemi\u00ed kon\u010detiny a vysok\u00fdm opera\u010dn\u00edm rizikem indikov\u00e1n axilofemor\u00e1ln\u00ed nebo bifemor\u00e1ln\u00ed bypass. Pro svou d\u00e9lku je tento bypass \u010dasto komplikov\u00e1n uz\u00e1v\u011bry.<\/li>\n<li style=\"text-align: justify;\">Hybridn\u00ed v\u00fdkony kombinuj\u00ed v jedn\u00e9 dob\u011b chirurgick\u00fd opera\u010dn\u00ed v\u00fdkon a v\u00fdkon endovaskul\u00e1rn\u00ed. Typick\u00fdm v\u00fdkonem je chirurgick\u00e1 trombendarterektomie femor\u00e1ln\u00ed vidlice a z tohoto p\u0159\u00edstupu potom o\u0161et\u0159en\u00ed sten\u00f3zy nebo uz\u00e1v\u011bru p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>N\u00e1sledn\u00e1 p\u00e9\u010de<br \/>\n<\/strong>Doporu\u010duje se trval\u00e1 terapie kyselinou acetylsali-cylovou v d\u00e1vce 100 mg\/den. P\u0159i zaveden\u00ed stentudo p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b se doporu\u010duje terapie clo-pidogrelem pod dobu 6 t\u00fddn\u016f. Je nutn\u00e1 kontrolametabolick\u00fdch chorob, jejich l\u00e9\u010dba nebo profylaxe.P\u0159edpokl\u00e1d\u00e1 se spolupr\u00e1ce nemocn\u00e9ho ve smyslupravideln\u00fdch klinick\u00fdch a UZ kontrol.<\/li>\n<\/ul>\n<h6>FEMOR\u00c1LN\u00cd \u0158E\u010cI\u0160T\u011a<\/h6>\n<ul>\n<li><strong>\u00davod<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b stehna je dnes v l\u00e9\u010db\u011b ischemick\u00e9 choroby doln\u00edch kon\u010detin v pop\u0159ed\u00ed z\u00e1jmu angiolog\u016f, chirurg\u016f a interven\u010dn\u00edch radio-log\u016f. Proto\u017ee ka\u017ed\u00fd obor nemocn\u00e9mu p\u0159in\u00e1\u0161\u00ed nov\u00e9 metody l\u00e9\u010dby, je k jejich pln\u00e9mu vyu\u017eit\u00ed pot\u0159ebn\u00e1 t\u011bsn\u00e1 spolupr\u00e1ce. Pod vlivem nov\u00fdch poznatk\u016f se dnes \u0159e\u0161\u00ed jako celek femoropoplite\u00e1ln\u00ed oblast od spole\u010dn\u00e9 femor\u00e1ln\u00ed arterie po trifurkaci poplite\u00e1ln\u00ed arterie.<\/li>\n<li style=\"text-align: justify;\">Ka\u017ed\u00fd druh\u00fd c\u00e9vn\u00ed uz\u00e1v\u011br doln\u00edch kon\u010detin postihuje femor\u00e1ln\u00ed vidlici a povrchn\u00ed stehen-n\u00ed tepnu (AFS). D\u016fsledek uz\u00e1v\u011bru povrchn\u00ed stehenn\u00ed tepny se u jednotliv\u00fdch nemocn\u00fdch li\u0161\u00ed. P\u0159i pr\u016fchodn\u00e9m p\u00e1nevn\u00edm \u0159e\u010di\u0161ti, voln\u00e9 hlubok\u00e9 stehenn\u00ed tepn\u011b a dobr\u00fdm kolater\u00e1ln\u00ed ob\u011bhem do poplite\u00e1ln\u00ed art\u00e9rie nemus\u00ed nemocn\u00fd p\u0159i uz\u00e1v\u011bru \u017e\u00e1dn\u00e9 nebo m\u00e1 minim\u00e1ln\u00ed pot\u00ed\u017ee.Asi u 1\/3 nemocn\u00fdch doch\u00e1z\u00ed k progresi ateroskler\u00f3zy a pot\u00ed\u017e\u00ed (klaudikace) a u dal\u0161\u00ed 1\/3 je progrese rychl\u00e1. Kritick\u00e1 ischemie se vyskytuje sporadicky. Mnohem t\u011b\u017e\u0161\u00ed pr\u016fb\u011bh m\u00e1 onemocn\u011bn\u00ed, pokud m\u00e1 nemocn\u00fd sou\u010dasn\u011b diabetes mellitus.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<\/strong>\n<ul style=\"text-align: justify;\">\n<li>Anamn\u00e9za, rizikov\u00e9 faktory.<\/li>\n<li>Fyzik\u00e1ln\u00ed vy\u0161et\u0159en\u00ed s d\u016frazem na inspekci (barva k\u016f\u017ee, ztr\u00e1ta svalov\u00e9 hmoty, ochlupen\u00ed, z\u00e1n\u011bty,defekty) = ischemick\u00e9 zm\u011bny. P\u0159i hodnocen\u00ed je t\u0159eba evidovat zm\u011bny vypl\u00fdvaj\u00edc\u00ed z jin\u00fdch onemocn\u011bn\u00ed, kter\u00e1 mohou p\u0159\u00edznaky ischemie ovlivnit (otoky, varixy, posttrombotick\u00fd sy, dermat\u00f3zy).<\/li>\n<li>Zhodnocen\u00ed pulzace oboustrann\u011b a ve v\u0161ech doporu\u010den\u00fdch et\u00e1\u017e\u00edch.<\/li>\n<li>B\u011bh\u00e1tko, ergometr \u2013 nemocn\u00ed \u010dasto nedok\u00e1\u017eou objektivizovat schopnost z\u00e1t\u011b\u017ee doln\u00edch kon\u010detin. Standardn\u00ed z\u00e1t\u011b\u017e je 3 km\/hod se stoup\u00e1n\u00edm12% k dosa\u017een\u00ed relevantn\u00edch pot\u00ed\u017e\u00ed.<\/li>\n<li>Barevn\u00e1 duplexn\u00ed sonografie zobraz\u00ed sten\u00f3zy a uz\u00e1v\u011bry povrchn\u00ed stehenn\u00ed tepny, z\u00e1sadn\u00ed v\u00fdznam m\u00e1 p\u0159i hodnocen\u00ed poplite\u00e1ln\u00ed arterie k vylou\u010den\u00ed jej\u00ed v\u00fddut\u011b.<\/li>\n<li>NMR ag je neinvazivn\u00ed metoda, kontrastn\u00ed l\u00e1tka se pod\u00e1v\u00e1 intraven\u00f3zn\u011b a p\u0159i vylou\u010den\u00ed jej\u00edch kontraindikac\u00ed m\u00e1 z\u00e1sadn\u00ed p\u0159\u00ednos v zobrazen\u00ed arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b (p\u0159i vy\u0161et\u0159en\u00ed se rozsah indikuje od abdomin\u00e1ln\u00ed aorty do periferie kon\u010detin). Kontraindikac\u00ed jsou PM, defibril\u00e1tory, kovov\u00fd materi\u00e1l (stav osteosynt\u00e9z\u00e1ch). Je t\u0159eba pe\u010dliv\u011b zv\u00e1\u017eit jej\u00ed indikaci u nemocn\u00fdch s ledvinn\u00fdm selh\u00e1n\u00ed, p\u0159edev\u0161\u00edm u dialyzovan\u00fdch nemocn\u00fdch.<\/li>\n<li>CT ag je rychl\u00e1 zobrazovac\u00ed metoda, jej\u00ed pou\u017eit\u00ed je spojeno s pod\u00e1n\u00edm kontrastn\u00ed l\u00e1tky a radia\u010dn\u00edm zat\u00ed\u017een\u00edm.<\/li>\n<li>Intraarteri\u00e1ln\u00ed DSA je kvalitn\u00ed zobrazuj\u00edc\u00ed invazivn\u00ed metoda \u2013 \u201ezlat\u00fd standard\u201c ve kvalit\u011b zobrazen\u00ed, dnes je p\u0159edev\u0161\u00edm ur\u010dena pro zobrazen\u00ed s navazuj\u00edc\u00ed endovaskul\u00e1rn\u00ed l\u00e9\u010dbou. Krom\u011b invazivity je spojena s pod\u00e1n\u00edm kontrastn\u00ed l\u00e1tky a rizikem alergick\u00e9 reakce.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Indikace k v\u00fdkonu<\/strong><br \/>\nP\u0159ed indikac\u00ed k chirurgick\u00e9mu nebo endovaskul\u00e1rn\u00edmu v\u00fdkonu pro sten\u00f3zu nebo uz\u00e1v\u011br AFS je v\u017edy t\u0159eba pe\u010dliv\u011b zhodnotit pot\u00ed\u017ee nemocn\u00e9ho, proto\u017ee konzervativn\u00ed terapie p\u0159i zn\u00e1m\u00e9 schopnosti kolater\u00e1ln\u00ed ob\u011bhu cestou arteria profunda femoris (APF)m\u016f\u017ee m\u00edt p\u0159ekvapiv\u011b dobr\u00fd efekt. Jasnou indikac\u00ed k v\u00fdkonu jsou pot\u00ed\u017ee odpov\u00eddaj\u00edc\u00ed FIII a FIV. Je t\u0159eba op\u011bt p\u0159ipomenout, \u017ee izolovan\u00fd uz\u00e1v\u011br AFS tyto pot\u00ed\u017ee ned\u011bl\u00e1. Jin\u00e1, v\u00fdrazn\u011bj\u0161\u00ed symptomatologie je u diabetik\u016f nebo u nemocn\u00fdch se sten\u00f3zou nebo uz\u00e1v\u011brem APF. Klinick\u00fd obraz se tak\u00e9 z\u00e1sadn\u011b m\u011bn\u00ed, kdy\u017e je s AFS posti\u017eena tak\u00e9 poplite\u00e1ln\u00ed arterie.<\/li>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010dba<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Perkut\u00e1nn\u00ed translumin\u00e1ln\u00ed angioplastika (PTA\/stent) je v sou\u010dasn\u00e9 dob\u011b metodou, kterou lze o\u0161et\u0159it sten\u00f3zy i uz\u00e1v\u011br y povrchn\u00ed stehenn\u00ed tepny. Krom\u011b klasick\u00e9 angioplastiky se metoda zkvalit\u0148uje pou\u017eit\u00edm stent\u016f nebo stentgraft\u016f. Za formu angioplastiky se pova\u017euje subintim\u00e1ln\u00ed rekanalizace (SIR) dlouh\u00fdch uzav\u0159en\u00fdch \u00fasek\u016f.<\/li>\n<li style=\"text-align: justify;\">Trombendarterektomie femor\u00e1ln\u00ed vidlice (se z\u00e1platou \u2013 patch). Snahou tohoto chirurgick\u00e9hov\u00fdkonu je v\u011bt\u0161inou zlep\u0161it p\u0159\u00edtok do APF, a t\u00edm zv\u00fd\u0161it kvalitu kolater\u00e1ln\u00edho ob\u011bhu. Izolovan\u00e1 sten\u00f3za APF s uz\u00e1v\u011brem AFS je vz\u00e1cn\u00e1, v\u011bt\u0161inou je posti\u017eena cel\u00e1 femor\u00e1ln\u00ed vidlice. Endarterektomuje se spole\u010dn\u00e1 femor\u00e1ln\u00ed arterie a APFdo jej\u00edho v\u011btven\u00ed. Uz\u00e1v\u011br arteriotomie se prov\u00e1d\u00ed pomoc\u00ed \u017eiln\u00ed nebo ePTFE z\u00e1platy (profundoplastika, patch). Z\u00e1plata roz\u0161i\u0159uje v\u00fdtokov\u00fd trakt. Profundoplastika nep\u0159in\u00e1\u0161\u00ed z\u00e1sadn\u00ed benefit nemocn\u00fdm ve stadiu FIII a FIV. V\u00fdkon na vidlici femor\u00e1ln\u00ed arterie je nezbytnou sou\u010d\u00e1st\u00ed hybridn\u00edho v\u00fdkonu.<\/li>\n<li style=\"text-align: justify;\">Bypass, obejit\u00ed uzav\u0159en\u00e9ho \u00faseku je mo\u017en\u00e9 pomoc\u00ed r\u016fzn\u00fdch materi\u00e1l\u016f \u2013 viz kapitola o c\u00e9vn\u00edch n\u00e1hrad\u00e1ch. Za nejkvalitn\u011bj\u0161\u00ed se dosud pova\u017euje autologn\u00ed \u017e\u00edla. P\u0159\u00edtok je zaji\u0161t\u011bn cestou spole\u010dn\u00e9 femor\u00e1ln\u00ed arterie, v\u00fdtok poplite\u00e1ln\u00ed arteri\u00ed v je-j\u00edm I. nebo III. \u00faseku (fotogalerie 4b).<\/li>\n<li style=\"text-align: justify;\">Hybridn\u00ed v\u00fdkony jsou jednodob\u00e9 kombinovan\u00e9 v\u00fdkony chirurgick\u00e9 a endovaskul\u00e1rn\u00ed, kter\u00fdmi se o\u0161et\u0159uj\u00ed v\u00edceet\u00e1\u017eov\u00e1 posti\u017een\u00ed arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b. Prov\u00e1d\u00ed se na tzv. hybridn\u00edch s\u00e1lech, kdy se jedn\u00e1 o aseptick\u00fd chirurgick\u00fd s\u00e1l, kter\u00fd je sou\u010dasn\u011b vybaven v\u00fdkonnou angiolinkou. Typick\u00fdmi v\u00fdkony jsou chirurgick\u00e9 o\u0161et\u0159en\u00ed femor\u00e1ln\u00ed vidlice (AFC a APF) a endovaskul\u00e1rn\u011b se zlep\u0161\u00ed p\u0159\u00edtok o\u0161et\u0159en\u00edm sten\u00f3zy nebo uz\u00e1v\u011bru spole\u010dn\u00e9 nebo zevn\u00ed ilick\u00e9 arterie. Cestou femor\u00e1ln\u00ed vidlice lze tak\u00e9 v r\u00e1mci hybridn\u00edho v\u00fdkonu o\u0161et\u0159it AFS a AP.<\/li>\n<li style=\"text-align: justify;\">Adjuvantn\u00ed sympatektomie se dnes chirurgicky prakticky jako samostatn\u00fd v\u00fdkon neprov\u00e1d\u00ed, p\u0159ipojuje se p\u0159i v\u00fdkonech na aort\u011b. U chirurgicky a endovaskul\u00e1rn\u011b ne\u0159e\u0161iteln\u00fdch stav\u016f se prov\u00e1d\u00ed jako samostatn\u00fd v\u00fdkon pod CT kontrolou destrukc\u00ed lumb\u00e1ln\u00edch gangli\u00ed alkoholem.<\/li>\n<\/ul>\n<\/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 4b:<br \/>\nfemoropoplite\u00e1ln\u00ed bypass<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\"><strong>Femoropoplite\u00e1ln\u00ed bypass \u2013 ag pravostrann\u00fd uz\u00e1v\u011br AFS<\/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_125.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"A\" alt=\"A\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_125.jpg\" width=\"200\" height=\"200\" \/><\/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_124.jpg\"><img decoding=\"async\" title=\"B\" alt=\"B\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_124.jpg\" width=\"200\" \/><\/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_128.jpg\"><img decoding=\"async\" title=\"C\" alt=\" C\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_128.jpg\" width=\"200\" \/><\/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_126.jpg\"><img decoding=\"async\" title=\"D\" alt=\"D\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_126.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">D<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" 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_129.jpg\"><img decoding=\"async\" title=\"E\" alt=\"E\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_129.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">E<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\"><strong>Proxim\u00e1ln\u00ed femoropoplite\u00e1n\u00ed bypass c\u00e9vn\u00ed prot\u00e9zou<\/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_131.png\"><img decoding=\"async\" title=\"Vypreparovan\u00e1 poplite\u00e1ln\u00ed arterie\" alt=\"Vypreparovan\u00e1 poplite\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_131.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vypreparovan\u00e1 poplite\u00e1ln\u00ed arterie<\/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_130.png\"><img decoding=\"async\" title=\"Vypreparovan\u00e1 femor\u00e1ln\u00ed arterie\" alt=\"Vypreparovan\u00e1 femor\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_130.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vypreparovan\u00e1 femor\u00e1ln\u00ed arterie<\/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_133.png\"><img decoding=\"async\" title=\"Vypreparovan\u00e1 autologn\u00ed safena, chab\u00fd kalibr, nepou\u017eiteln\u00e1 k bypassu\" alt=\"Vypreparovan\u00e1 autologn\u00ed safena, chab\u00fd kalibr, nepou\u017eiteln\u00e1 k bypassu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_133.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vypreparovan\u00e1 autologn\u00ed safena, chab\u00fd kalibr, nepou\u017eiteln\u00e1 k bypassu<\/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_134.png\"><img decoding=\"async\" title=\"ePTF prot\u00e9za I.\" alt=\"ePTF prot\u00e9za I.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_134.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">ePTF prot\u00e9za I.<\/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_135.png\"><img loading=\"lazy\" decoding=\"async\" title=\"ePTF prot\u00e9za II.\" alt=\"ePTF prot\u00e9za II.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_135.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">ePTF prot\u00e9za 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_136.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"ePTF prot\u00e9za III.\" alt=\"ePTF prot\u00e9za III.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_136.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">ePTF prot\u00e9za III.<\/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_138.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Mo\u017enost podko\u017en\u00edho ulo\u017een\u00ed prot\u00e9zy\" alt=\"Mo\u017enost podko\u017en\u00edho ulo\u017een\u00ed prot\u00e9zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_138.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">Mo\u017enost podko\u017en\u00edho ulo\u017een\u00ed prot\u00e9zy<\/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_137.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Typick\u00e9 ulo\u017een\u00ed anatomick\u00e9 prot\u00e9zy\" alt=\"Typick\u00e9 ulo\u017een\u00ed anatomick\u00e9 prot\u00e9zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_137.png\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">Typick\u00e9 ulo\u017een\u00ed anatomick\u00e9 prot\u00e9zy<\/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_140.png\"><img decoding=\"async\" title=\"Femor\u00e1ln\u00ed arterie, p\u0159\u00edtok\" alt=\"Femor\u00e1ln\u00ed arterie, p\u0159\u00edtok\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_140.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Femor\u00e1ln\u00ed arterie, p\u0159\u00edtok<\/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_141.png\"><img decoding=\"async\" title=\"Proxim\u00e1ln\u00ed femor\u00e1ln\u00ed anastom\u00f3za\" alt=\"Proxim\u00e1ln\u00ed femor\u00e1ln\u00ed anastom\u00f3za\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_141.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Proxim\u00e1ln\u00ed femor\u00e1ln\u00ed anastom\u00f3za<\/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_143.png\"><img decoding=\"async\" title=\"Poplite\u00e1ln\u00ed arterie, v\u00fdtokov\u00fd trak\" alt=\"Poplite\u00e1ln\u00ed arterie, v\u00fdtokov\u00fd trak\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_143.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Poplite\u00e1ln\u00ed arterie, v\u00fdtokov\u00fd trak<\/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_142.png\"><img decoding=\"async\" title=\"P\u0159\u00edprava dist\u00e1ln\u00ed anastom\u00f3zy\" alt=\"P\u0159\u00edprava dist\u00e1ln\u00ed anastom\u00f3zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_142.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">P\u0159\u00edprava dist\u00e1ln\u00ed anastom\u00f3zy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" 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_144.png\"><img decoding=\"async\" title=\"Dist\u00e1ln\u00ed poplite\u00e1ln\u00ed anastom\u00f3za\" alt=\"Dist\u00e1ln\u00ed poplite\u00e1ln\u00ed anastom\u00f3za\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_144.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Dist\u00e1ln\u00ed poplite\u00e1ln\u00ed anastom\u00f3za<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\"><strong>N\u00e1sledn\u00e1 p\u00e9\u010de<br \/>\n<\/strong>V poopera\u010dn\u00edm obdob\u00ed je indikov\u00e1na antiagrega\u010dn\u00ed terapie dle rozsahu v\u00fdkonu (kyselina acetylsalicylov\u00e1, clopidogrel). U \u017eiln\u00edho femoropoplite\u00e1ln\u00edho bypassu je mo\u017en\u00e1 tak\u00e9 terapie antikoagula\u010dn\u00ed.Pro zaji\u0161t\u011bn\u00ed dlouhodob\u00fdch v\u00fdsledk\u016f se p\u0159edpokl\u00e1d\u00e1 spolupr\u00e1ce nemocn\u00e9ho ve smyslu pravideln\u00fdch klinick\u00fdch a UZ kontrol. P\u0159i klinick\u00e9m zhor\u0161en\u00ed stavu nebo p\u0159i progresi n\u00e1lezu p\u0159i UZ vy\u0161et\u0159en\u00ed, kdy se zva\u017euje dal\u0161\u00ed chirurgick\u00fd nebo endovaskul\u00e1rn\u00ed v\u00fdkon, je indikov\u00e1na n\u011bkter\u00e1 z angiografick\u00fdch metod.<\/li>\n<\/ul>\n<h6>POPLITE\u00c1LN\u00cd ARTERIE<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>\u00davod<\/strong><br \/>\nT\u00e9m\u011b\u0159 50% sten\u00f3z a uz\u00e1v\u011br\u016f art\u00e9ri\u00ed doln\u00edch kon\u010detin je lokalizov\u00e1no v \u0159e\u010di\u0161ti femor\u00e1ln\u00ed a poplite\u00e1ln\u00ed arterie. Tyto zm\u011bny jsou v\u011bt\u0161inou zp\u016fsobeny obliteruj\u00edc\u00ed ateroskler\u00f3zou. Posti\u017een\u00ed nemocn\u00ed jsou ve v\u011bku 60\u201370 let. Pokud se objev\u00ed klaudikace nebo jin\u00e9 pot\u00ed\u017ee u mlad\u0161\u00edch nemocn\u00fdch, je t\u0159eba mys-let na jin\u00e9 ne\u017e aterosklerotick\u00e9 p\u0159\u00ed\u010diny. Obecn\u011b lzeetiologii onemocn\u011bn\u00ed rozd\u011blit na:<\/p>\n<ul>\n<li>ateroskler\u00f3za arteria poplitea (cca 85%),<\/li>\n<li>entrapment arteria poplitea (cca 1\u20133%),<\/li>\n<li>cystick\u00e1 degenerace adventitie arteria poplitea (cca 1\u20132%),<\/li>\n<li>aneurysma arteria poplitea (cca 3\u20137%),<\/li>\n<li>trauma (20\u201330% arteri\u00e1ln\u00edch poran\u011bn\u00ed postihuje poplite\u00e1ln\u00ed arterii),<\/li>\n<li>jin\u00e9: fibromuskul\u00e1rn\u00ed dysplazie, kompresivn\u00ed sy adduktorsk\u00e9ho kan\u00e1lu, kongenit\u00e1ln\u00ed aplazienebo dysplazie arterie).<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>P\u0159\u00edznaky<\/strong>\n<ul>\n<li>\u00a0bolesti l\u00fdtka p\u0159i z\u00e1t\u011b\u017ei (klaudikace) a\u017e klidov\u00e9 bolesti,<\/li>\n<li>pocit chladu,<\/li>\n<li>dysestezie,<\/li>\n<li>parestezie akr\u00e1ln\u00edch \u010d\u00e1st\u00ed kon\u010detin,<\/li>\n<li>kr\u00e1ln\u00ed nekr\u00f3zy.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<br \/>\n<\/strong>Oblig\u00e1tn\u011b se jedn\u00e1 o anamn\u00e9zu a podrobn\u00e9 klinick\u00e9 vy\u0161et\u0159en\u00ed se zam\u011b\u0159en\u00edm na:<\/p>\n<ul>\n<li style=\"text-align: justify;\">celkov\u00e9 obecn\u00e9 vy\u0161et\u0159en\u00ed nemocn\u00e9ho,<\/li>\n<li>zhodnocen\u00ed lok\u00e1ln\u00edch zm\u011bn:\n<ul>\n<li style=\"text-align: justify;\">barva k\u016f\u017ee,<\/li>\n<li style=\"text-align: justify;\">teplota k\u016f\u017ee,<\/li>\n<li style=\"text-align: justify;\">trofick\u00e9 ko\u017en\u00ed zm\u011bny, otoky,<\/li>\n<li style=\"text-align: justify;\">vy\u0161et\u0159en\u00ed pulzac\u00ed na typick\u00fdch m\u00edstech se stranov\u00fdm srovn\u00e1n\u00edm,<\/li>\n<li style=\"text-align: justify;\">palpa\u010dn\u00ed vy\u0161et\u0159en\u00ed (v\u00fddu\u0165),<\/li>\n<li style=\"text-align: justify;\">poslechov\u00e9 vy\u0161et\u0159en\u00ed \u2013 p\u0159\u00edtomnost \u0161elest\u016f,<\/li>\n<li style=\"text-align: justify;\">kapil\u00e1rn\u00ed n\u00e1vrat,<\/li>\n<li style=\"text-align: justify;\">lok\u00e1ln\u00ed neurologick\u00e9 vy\u0161et\u0159en\u00ed (citlivost, motorika).N\u00e1sleduj\u00ed speci\u00e1ln\u00ed vy\u0161et\u0159en\u00ed s ohledem na p\u0159edpokl\u00e1dan\u00fd druh onemocn\u011bn\u00ed poplite\u00e1ln\u00ed arterie.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Ateroskler\u00f3za AP<br \/>\n<\/strong>M\u00e1 typick\u00e9 projevy odpov\u00eddaj\u00edc\u00ed nap\u0159. Fontainov\u011b klasifikaci. Vy\u0161et\u0159ovac\u00ed metody by m\u011bly b\u00fdt pou\u017eity v uveden\u00e9m po\u0159ad\u00ed. Z\u00e1sadn\u00ed je, zda nemocn\u00fd m\u00e1 z\u00e1jem o chirurgickou nebo endovaskul\u00e1rn\u00ed l\u00e9\u010dbu.Pokud chce b\u00fdt l\u00e9\u010den jen konzervativn\u011b, nemaj\u00ed angiografick\u00e9 zobrazovac\u00ed metody praktick\u00fd v\u00fdznam.<\/p>\n<ul>\n<li>P\u0159\u00edm\u00e1 sonografie, duplexn\u00ed nebo barevn\u00e1 duplexn\u00ed sonografie: p\u0159edstavuj\u00ed z\u00e1kladn\u00ed (standardn\u00ed) vy\u0161et\u0159ovac\u00ed metody arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b. Umo\u017en\u00ed zhodnocen\u00ed pr\u016ftoku vy\u0161et\u0159ovan\u00e9m \u0159e\u010di\u0161ti a vyhodnocen\u00ed AB indexu. Limitaci p\u0159edstavuj\u00ed nekompresibiln\u00ed arterie (nelze ABI), nap\u0159.p\u0159i diabetes mellitus.<\/li>\n<li>MR-angiografie zobrazuje arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b od abdomin\u00e1ln\u00ed aorty do periferie, je minim\u00e1ln\u011b invazivn\u00ed, lze ji pou\u017e\u00edt p\u0159i alergii na kontrastn\u00ed l\u00e1tky. Nev\u00fdhodou m\u016f\u017ee b\u00fdt nep\u0159esnost p\u0159i hodnocen\u00ed stupn\u011b sten\u00f3zy ve srovn\u00e1n\u00ed s intraarteri\u00e1ln\u00ed subtrak\u010dn\u00ed angiografi\u00ed (viz d\u00e1le).<\/li>\n<li>CT angiografie \u2013 jej\u00ed v\u00fdhodou je mal\u00e1 invazivita v\u00fdkonu, zobrazen\u00ed i okoln\u00edch struktur, rychlost vy\u0161et\u0159en\u00ed. Nev\u00fdhodou je vysok\u00e9 radia\u010dn\u00ed zat\u00ed\u017een\u00ed.<\/li>\n<li>Intraarteri\u00e1ln\u00ed subtrak\u010dn\u00ed angiografie \u2013 jej\u00ed u\u017eit\u00ed je nejvhodn\u011bj\u0161\u00ed k zobrazen\u00ed cel\u00e9ho arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b od abdomin\u00e1ln\u00ed aorty do periferie kon\u010detin (v\u010detn\u011b plant\u00e1rn\u00edho oblouku). Nepou\u017eiteln\u00e1 p\u0159i alergii na kontrastn\u00ed l\u00e1tky, dal\u0161\u00ed nev\u00fdhodou je invazivita a radiace.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Entrapment AP<br \/>\n<\/strong>P\u0159edstavuje vz\u00e1cn\u00e9 onemocn\u011bn\u00ed, kter\u00e9 m\u00e1 p\u0159\u00ed\u010dinu v anatomick\u00e9 anom\u00e1lii. M\u00e1 n\u011bkolik morfologick\u00fdch variant, ale spole\u010dn\u00e9 je, \u017ee svalov\u00e9 struktury v z\u00e1kolenn\u00ed jamce komprimuj\u00ed poplite\u00e1ln\u00ed arterii. Lze rozpoznat 3 typy:<\/p>\n<ul>\n<li>arterie m\u00e1 anatomick\u00fd spr\u00e1vn\u00fd pr\u016fb\u011bh a jej\u00ed \u00fatlak je zp\u016fsoben kongenit\u00e1ln\u00edmi svalov\u00fdmi anom\u00e1liemi,<\/li>\n<li>svalov\u00e9 \u00fapony jsou anatomicky spr\u00e1vn\u00e9, ale arterie m\u00e1 anom\u00e1ln\u00ed pr\u016fb\u011bh,<\/li>\n<li>kombinace obou anom\u00e1li\u00ed.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Klinickou diagn\u00f3zu onemocn\u011bn\u00ed podporuje v\u011bk nemocn\u00e9ho (pod 40 let) a d\u00e1le, \u017ee jej\u00ed projevy(klaudikace) jsou spojeny v\u011bt\u0161inou se sportovn\u00edm zat\u00ed\u017een\u00edm mlad\u00fdch mu\u017e\u016f. Standardn\u00ed vy\u0161et\u0159ovac\u00ed postup:\n<ul>\n<li>sledov\u00e1n\u00ed klinick\u00e9ho n\u00e1lezu = kvality (ztr\u00e1ta) pulzace na periferii kon\u010detiny p\u0159i provoka\u010dn\u00edch testech \u2013 p\u0159i dorz\u00e1ln\u00ed nebo plant\u00e1rn\u00ed flexi nohy,p\u0159i extenzi v kolenn\u00edm kloubu,<\/li>\n<li>sonografick\u00e9 vy\u0161et\u0159en\u00ed AP k vylou\u010den\u00ed cystick\u00e9 degenerace adventitie a v\u00fddut\u011b poplite\u00e1ln\u00ed arte-rie,<\/li>\n<li>MR-angiografie, zobraz\u00ed pr\u016fb\u011bh arterie ve vztahu k m\u011bkk\u00fdm struktur\u00e1m okol\u00ed (kvalitn\u011bji ne\u017eCT ag),<\/li>\n<li>CT-angiografie,<\/li>\n<li>intraarteri\u00e1ln\u00ed subtrak\u010dn\u00ed angiografie.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Cystick\u00e1 degenerace AP<\/strong><br \/>\nP\u0159edstavuje vz\u00e1cn\u00e9 onemocn\u011bn\u00ed arteri\u00e1ln\u00ed st\u011bny.Z patologick\u00e9ho hlediska se jedn\u00e1 o tvorbu cystv subadventiti\u00e1ln\u00edm prostoru s mukoidn\u00ed degenerac\u00ed adventiti\u00e1ln\u00ed pojivov\u00e9 tk\u00e1n\u011b. D\u016fsledkem je komprese arteri\u00e1ln\u00edho lumina. Projevuje se ve 3.\u20134. dek\u00e1d\u011b \u017eivota. Vy\u0161et\u0159ovac\u00ed metody jsou:podrobn\u00e9 klinick\u00e9 vy\u0161et\u0159en\u00ed, UZ z\u00e1kolenn\u00ed jamkya n\u011bkter\u00e1 z angiografick\u00fdch metod, nejl\u00e9pe NMRag nebo CT ag (fotogalerie 4c).<\/li>\n<li>Aneuryzma AP (AAP)\n<ul>\n<li style=\"text-align: justify;\">Jedn\u00e1 se po aneuryzmatu abdomin\u00e1ln\u00ed aorty<\/li>\n<li style=\"text-align: justify;\">Druh\u00fd nej\u010dast\u011bj\u0161\u00ed typ v\u00fddut\u011b. Asi u poloviny nemocn\u00fdch je v\u00fdskyt AAP oboustrann\u00fd. Asi40\u201350% nemocn\u00fdch m\u00e1 v\u00fddu\u0165 abdomin\u00e1ln\u00ed aorty. 97% AAP postihuje mu\u017ee.<br \/>\nSymptomatick\u00e9 AAP ohro\u017euje kon\u010detinu ischemi\u00ed s vysok\u00fdm rizikem amputace (25\u201330%). Tito nemocn\u00ed maj\u00ed vysokou morbiditu a mortalitu. Asymptomatick\u00e9 AAP m\u00e1 riziko komplikace 24% ji\u017e v prvn\u00edm roce po stanoven\u00ed diagn\u00f3zy.<\/li>\n<li style=\"text-align: justify;\">Nep\u0159\u00edzniv\u00e1 progn\u00f3za symptomatick\u00e9ho AAP vypl\u00fdv\u00e1 z recidivuj\u00edc\u00edch okultn\u00edch perifern\u00edch embolizac\u00ed, jejich\u017e zdrojem je AAP. Embolizace v\u00fdrazn\u011b po\u0161kozuj\u00ed v\u00fdtokov\u00fd trakt. Na vlastn\u00ed \u00fapln\u00e9 tromb\u00f3ze AAP se nekvalitn\u00ed v\u00fdtokov\u00fd trakt z\u00e1sadn\u011b pod\u00edl\u00ed. Ruptura AAP se vyskytuje asi u 10% v\u00fddut\u00ed.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Standardn\u00ed vy\u0161et\u0159ovac\u00ed metody jsou sonografie, CT a angiografie. Je t\u0159eba vy\u0161et\u0159it ob\u011b kon\u010detiny.<\/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 4c:<\/h6>\n<h6>cystick\u00e1 degenerace poplite\u00e1ln\u00ed arterie<\/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_148.jpg\"><img decoding=\"async\" title=\"Cystick\u00e1 degenerace AP I.\" alt=\"Cystick\u00e1 degenerace AP I.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_148.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Cystick\u00e1 degenerace AP I.<\/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_147.jpg\"><img decoding=\"async\" title=\"Cystick\u00e1 degenerace AP II.\" alt=\"Cystick\u00e1 degenerace AP II.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_147.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Cystick\u00e1 degenerace AP II.<\/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_150.jpg\"><img decoding=\"async\" title=\"Cystick\u00e1 degenerace AP, resekovan\u00e1 arterie s cystou\" alt=\"Cystick\u00e1 degenerace AP, resekovan\u00e1 arterie s cystou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_150.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Cystick\u00e1 degenerace AP, resekovan\u00e1 arterie s cystou<\/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_149.jpg\"><img decoding=\"async\" title=\"Cystick\u00e1 degenerace AP, obsah cysty\" alt=\"Cystick\u00e1 degenerace AP, obsah cysty\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_149.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Cystick\u00e1 degenerace AP, obsah cysty<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>INDIKACE K V\u00ddKONU A TERAPIE<\/h6>\n<ul>\n<li style=\"text-align: justify;\">Uz\u00e1v\u011br p\u0159i ateroskler\u00f3ze<\/li>\n<li style=\"text-align: justify;\">Indikace k v\u00fdkonu je d\u00e1na n\u00e1lezem dle Fontainovy klasifikace:\n<ul style=\"text-align: justify;\">\n<li>Stadium I: sten\u00f3zy a uz\u00e1v\u011bry bez klinick\u00fdch projev\u016f.<\/li>\n<li>Stadium IIa: bezbolestn\u00e1 ch\u016fze p\u0159i standardn\u00edm zat\u00ed\u017een\u00ed nad vzd\u00e1lenost 200 m.<\/li>\n<li>Stadium IIb: bezbolestn\u00e1 ch\u016fze p\u0159i standardn\u00edm zat\u00ed\u017een\u00ed pod vzd\u00e1lenost 200 m.<\/li>\n<li>Stadium III: klidov\u00e9 bolesti.<\/li>\n<li>Stadium IV: spont\u00e1nn\u00ed tk\u00e1\u0148ov\u00e9 l\u00e9ze.<\/li>\n<li>U asymptomatick\u00e9ho stadia I nen\u00ed indikov\u00e1na ani invazivn\u00ed diagnostika, ani terapie. Ve stadiu IIa nejsou tak\u00e9 v\u011bt\u0161inou invazivn\u00ed postupy indikov\u00e1ny. Tak\u00e9 ve stadiu IIb by m\u011bly b\u00fdt pou\u017eity nejd\u0159\u00edve konzervativn\u00ed postupy, ale ve stadi\u00edch III a IV jsou absolutn\u00ed indikac\u00ed chirurgick\u00e9 nebo endovaskul\u00e1rn\u00ed metody.<\/li>\n<li>Indika\u010dn\u00ed rozvaha vy\u017eaduje u hrani\u010dn\u00edch n\u00e1lez\u016f Fontainovy klasifikace individu\u00e1ln\u00ed zhodnocen\u00ed celkov\u00e9ho stavu nemocn\u00e9ho \u2013 nap\u0159. \u017eivotn\u00ed podm\u00ednky nebo dlouhodobou progn\u00f3zu celkov\u00e9ho stavu.<\/li>\n<li>Koncepce l\u00e9\u010dby aterosklerotick\u00e9ho uz\u00e1v\u011bru poplite\u00e1ln\u00ed arterie je modifikov\u00e1na:\n<ul>\n<li>anatomickou lokalizac\u00ed posti\u017een\u00e9ho \u00faseku (P I, P II, P III),<\/li>\n<li>d\u00e9lkou uz\u00e1v\u011bru,<\/li>\n<li>klinick\u00fdm obrazem,<\/li>\n<li>v\u011bkem nemocn\u00e9ho.<\/li>\n<\/ul>\n<\/li>\n<li>Kr\u00e1tk\u00e9 uz\u00e1v\u011bry segmentu P I jsou indikov\u00e1ny k endovaskul\u00e1rn\u00ed l\u00e9\u010db\u011b \u2013 PTA. V\u00fdskyt resten\u00f3z je asi 40% b\u011bhem dvou let. Lep\u0161\u00ed v\u00fdsledky lze o\u010dek\u00e1vat, pokud je tato metoda spojena s implantac\u00ed stentu. Indikace k jeho zaveden\u00ed je p\u0159\u00edsn\u011b individu\u00e1ln\u00ed, proto\u017ee p\u0159i uz\u00e1v\u011bru stentu je mo\u017enost vyu\u017eit\u00ed tohoto arteri\u00e1ln\u00edho \u00faseku k chirurgick\u00e9mu bypassu velmi limitov\u00e1na. Na zachov\u00e1n\u00ed potenci\u00e1ln\u00edch arteri\u00e1ln\u00edch segment\u016f v\u00fdtokov\u00e9ho traktu bypassu je t\u0159eba do budoucnosti myslet a p\u0159i endovaskul\u00e1rn\u00edm v\u00fdkonu je nechat voln\u00e9.<\/li>\n<li>Z chirurgick\u00e9ho hlediska se od trombendarterektomi\u00ed poplite\u00e1ln\u00ed arterie ustoupilo a je indikov\u00e1n popliteo-poplite\u00e1ln\u00ed nebo femoropoplite\u00e1ln\u00ed bypass. Materi\u00e1l pou\u017eit\u00fd k bypassu je d\u00e1n zku\u0161enost\u00ed centra, p\u0159i rekonstrukc\u00edch na P III je nejvhodn\u011bj\u0161\u00ed (pokud je k dispozici) autologn\u00ed \u017eiln\u00ed transplant\u00e1t. \u017diln\u00ed bypass m\u016f\u017ee b\u00fdt reverz-n\u00ed, non-reverzn\u00ed nebo in situ. Nejb\u011b\u017en\u011bj\u0161\u00ed formafemoropoplite\u00e1n\u00edho bypassu je reverzn\u00ed bypass. Pr\u016fchodnost jednotliv\u00fdch typ\u016f \u017eiln\u00edch bypass\u016f je v z\u00e1sad\u011b stejn\u00e1.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Entrapment<\/strong><br \/>\nJasnou metodou volby je chirurgick\u00e1 l\u00e9\u010dba, kter\u00e1 zajist\u00ed dekompresi zpo\u010d\u00e1tku zdrav\u00e9 arterie prot\u011bt\u00ed mutla\u010duj\u00edc\u00edch vazivov\u00fdch pruh\u016f nebo sval\u016f. Dlouho-dob\u011b p\u016fsob\u00edc\u00ed entrapment chronicky traumatizuje arterii, st\u011bna arterie se patologicky m\u011bn\u00ed a vznikaj\u00ed segment\u00e1ln\u00ed sten\u00f3zy, uz\u00e1v\u011bry nebo aneuryzmata. Tyto zm\u011bny potom vy\u017eaduj\u00ed c\u00e9vn\u00ed rekonstruk\u010dn\u00ed v\u00fdkon. Nejb\u011b\u017en\u011bj\u0161\u00ed v\u00fdkon je z dorz\u00e1ln\u00edho p\u0159\u00edstupu resekce posti\u017een\u00e9 arterie a jej\u00ed n\u00e1hrada \u017eiln\u00edm interpon\u00e1tem.<\/li>\n<li style=\"text-align: justify;\"><strong>Cystick\u00e1 degenerace adventitie<\/strong>\n<ul style=\"text-align: justify;\">\n<li>Tak\u00e9 u tohoto onemocn\u011bn\u00ed je indikov\u00e1na chirurgick\u00e1 l\u00e9\u010dba \u2013 tedy resekce posti\u017een\u00e9ho \u00faseku arterie a jej\u00ed n\u00e1hrada \u017eiln\u00edm interpon\u00e1tem. Je t\u0159eba db\u00e1t na dokonal\u00e9 odstran\u011bn\u00ed cysty, kter\u00e1 m\u016f\u017ee b\u00fdt v t\u011bsn\u00e9m kontaktu s kloubn\u00edm pouzdrem. Jinou opera\u010dn\u00ed metodu p\u0159edstavuje snesen\u00ed cysts adventiti\u00ed a s ponech\u00e1n\u00edm vlastn\u00ed arterie.<\/li>\n<li>Perkut\u00e1nn\u00ed punkce cyst m\u00e1 vysok\u00fd po\u010det recidiv a pova\u017euje se za obsolentn\u00ed.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Aneuryzma poplite\u00e1ln\u00ed arterie<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Indikace k c\u00e9vn\u00ed rekonstrukci asymptomatick\u00e9 v\u00fddut\u011b vypl\u00fdv\u00e1 z mo\u017en\u00fdch komplikac\u00ed tohoto onemocn\u011bn\u00ed. Akutn\u00ed kritick\u00e1 ischemie n\u00e1sledkem AAP m\u00e1 riziko amputace 25\u201350%.P\u0159\u00ed\u010dinou \u0161patn\u00e9 progn\u00f3zy jsou okultn\u00ed mikroembolizace z v\u00fddut\u011b, kter\u00e9 zp\u016fsobuj\u00ed sukcesivn\u00ed obliterace b\u00e9rcov\u00fdch arteri\u00ed.<\/li>\n<li style=\"text-align: justify;\">Opera\u010dn\u00ed terapie je reprezentov\u00e1na nej\u010dast\u011bji \u017eiln\u00edm bypassem. Kombinovan\u00e1 p\u0159edopera\u010dn\u00ednebo intraopera\u010dn\u00ed trombolytick\u00e1 terapie s n\u00e1 sledn\u00fdm bypassem p\u0159i akutn\u00ed isch\u00e9mii v\u00fdrazn\u011b zlep\u0161\u00ed stav v\u00fdtokov\u00e9ho traktu<\/li>\n<li style=\"text-align: justify;\">Indikace k \u0159e\u0161en\u00ed asymptomatick\u00e9 v\u00fddut\u011b:\n<ul>\n<li style=\"text-align: justify;\">velikost nad 2 cm, ev. elongace arterie,<\/li>\n<li style=\"text-align: justify;\">nemocn\u00ed, kte\u0159\u00ed maj\u00ed jin\u00e1 operovan\u00e1 arteri\u00e1ln\u00ed onemocn\u011bn\u00ed (anastom\u00f3zy, pseudov\u00fddut\u011b).Indikace k \u0159e\u0161en\u00ed symptomatick\u00e9 v\u00fddut\u011b:<\/li>\n<li style=\"text-align: justify;\">emboliza\u010dn\u00ed nebo ischemick\u00e9 komplikace,<\/li>\n<li style=\"text-align: justify;\">lok\u00e1ln\u00ed \u00fatlak,<\/li>\n<li style=\"text-align: justify;\">septick\u00e9 aneuryzma.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/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=\"6\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 4d<br \/>\nAAP \u2013 stentgraft, viabahn<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"3\" 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_153.gif\"><img decoding=\"async\" title=\"Vinut\u00e9 p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011bVinut\u00e9 p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b\" alt=\"Vinut\u00e9 p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_153.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vinut\u00e9 p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"3\" 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_152.gif\"><img decoding=\"async\" title=\"Stehenn\u00ed \u0159e\u010di\u0161t\u011b\" alt=\"Stehenn\u00ed \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_152.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Stehenn\u00ed \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"3\" 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_155.gif\"><img decoding=\"async\" title=\"V\u00fddu\u0165 prav\u00e9 poplite\u00e1ln\u00ed arterie\" alt=\"V\u00fddu\u0165 prav\u00e9 poplite\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_155.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">V\u00fddu\u0165 prav\u00e9 poplite\u00e1ln\u00ed arterie<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"3\" 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_156.gif\"><img decoding=\"async\" title=\"Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b I.\" alt=\"Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b I.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_156.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b I.<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_157.gif\"><img decoding=\"async\" class=\" \" title=\"Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b II.\" alt=\"Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b II.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_157.gif\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Perifern\u00ed arteri\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b II.<\/p><\/div><\/td>\n<td style=\"width: 33%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_158.gif\"><img decoding=\"async\" class=\"  \" title=\"V\u00fddu\u0165 AP, zavedeno instrument\u00e1rium pro zaveden\u00ed stentgraft u viabahn\" alt=\"V\u00fddu\u0165 AP, zavedeno instrument\u00e1rium pro zaveden\u00ed stentgraft u viabahn\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_158.gif\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">V\u00fddu\u0165 AP, zavedeno instrument\u00e1rium pro zaveden\u00ed stentgraft u viabahn<\/p><\/div><\/td>\n<td style=\"width: 34%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_159.gif\"><img decoding=\"async\" class=\" \" title=\"Stav po zaveden\u00ed stentgraft u\" alt=\"Stav po zaveden\u00ed stentgraft u\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_159.gif\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Stav po zaveden\u00ed stentgraft u<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">\u00a0Opera\u010dn\u00ed \u0159e\u0161en\u00ed: medi\u00e1ln\u00edm nebo zadn\u00edm p\u0159\u00edstupem podvaz (exkluze) v\u00fddut\u011b a \u017eiln\u00ed bypass.U rizikov\u00fdch nemocn\u00fdch (a po p\u0159\u00edsn\u00e9m v\u00fdb\u011bru) lze jako potenci\u00e1ln\u00ed alternativu chirurgick\u00e9mu v\u00fdkonu nab\u00eddnout o\u0161et\u0159en\u00ed v\u00fddut\u011b stentgraftem (fotogalerie 4d).Akutn\u00ed kon\u010detinov\u00e1 ischemie zp\u016fsoben\u00e1 uz\u00e1v\u011brem AAP m\u00e1 teoreticky zd\u016fvodn\u011bnou preopera\u010dn\u00ed intraarteria\u00e1ln\u00ed trombolytickou l\u00e9\u010dbu. Ta umo\u017en\u00ed p\u0159edopera\u010dn\u00ed rekanalizaci uzav\u0159en\u00e9ho b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b, kter\u00e9 by nebylo z\u0159ejm\u011b mo\u017en\u00e9 o\u0161et\u0159it se stejn\u00fdm efektem mechanickou trombembolektomi\u00ed. Teoreticky lze uva\u017eovat o trombolytick\u00e9 l\u00e9\u010db\u011b AAP jako o samostatn\u00e9 terapii uzav\u0159en\u00e9 AP, je v\u0161ak nutno p\u0159ipustit mo\u017en\u00e9 komplikace:<\/p>\n<ul style=\"text-align: justify;\">\n<li>p\u0159i l\u00fdze se uvoln\u00ed emboliza\u010dn\u00ed materi\u00e1l, kter\u00fd uzav\u0159e perifern\u00ed \u0159e\u010di\u0161t\u011b a nen\u00ed d\u00e1le l\u00fdzou odstraniteln\u00fd. D\u016fsledkem m\u016f\u017ee b\u00fdt amputace kon\u010detiny;<\/li>\n<li>progn\u00f3za \u00fasp\u011bchu trombol\u00fdzy nen\u00ed p\u0159edv\u00eddateln\u00e1, proto\u017ee aneuryzmatick\u00e9 tromby jsou sm\u011bs\u00ed trombotick\u00e9ho materi\u00e1lu r\u016fzn\u00e9ho st\u00e1\u0159\u00ed. Jejich schopnost l\u00fdzy je r\u016fzn\u00e1;<\/li>\n<li>i p\u0159i region\u00e1ln\u00ed trombolytick\u00e9 l\u00e9\u010db\u011b mohou nastat celkov\u00e9 komplikace l\u00fdzy;<\/li>\n<li>p\u0159edev\u0161\u00edm u drobn\u00fdch arteri\u00ed se p\u016fsobnost trombolytika sni\u017euje a metoda selh\u00e1v\u00e1. P\u0159\u00ed\u010dinou je mal\u00e1 plocha arterie, kde m\u016f\u017ee trombolytikum p\u016fsobit.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">U \u010derstv\u00fdch uz\u00e1v\u011br\u016f m\u00e1 v\u00fdznam intraopera\u010dn\u00ed trombolytick\u00e1 l\u00e9\u010dba. Zlep\u0161uje kvalitu v\u00fdtokov\u00e9ho traktu. V\u00fdznam l\u00fdzy v\u0161ak nespo\u010d\u00edv\u00e1 rekanalizaci nejmen\u0161\u00edch arteri\u00ed, proto\u017ee zmen\u0161uj\u00edc\u00ed se kalibr arterie sni\u017euje \u00fa\u010dinnou plochu trombolytika a jej\u00ed \u00fa\u010dinnost v t\u00e9to et\u00e1\u017ei kles\u00e1.<\/p>\n<h6>B\u00c9RCOV\u00c9 \u0158E\u010cI\u0160T\u011a<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>\u00davod<\/strong><br \/>\nU nemocn\u00fdch s klinick\u00fdm n\u00e1lezem F III\u2013F IV lze p\u0159edpokl\u00e1dat, \u017ee p\u0159\u00ed\u010dinou jejich pot\u00ed\u017e\u00ed nebo sena jejich pot\u00ed\u017e\u00edch pod\u00edlej\u00ed aterosklerotick\u00e9 sten\u00f3zy nebo uz\u00e1v\u011bry b\u00e9rcov\u00fdch arteri\u00ed. Jen asi u 2%nemocn\u00fdch je p\u016fvod pot\u00ed\u017e\u00ed v trombangoitis obliterans. Asi polovina nemocn\u00fdch m\u00e1 sou\u010dasn\u011b diabetes mellitus. Aterosklerotick\u00fd proces postihuje nej\u010dast\u011bji a. tibialis anterior (ATA), potom a. tibialis posterior (ATP) a na t\u0159et\u00edm m\u00edst\u011b je a. fibularis(AF). Chronick\u00e1 perifern\u00ed ischemie ohro\u017euje nemocn\u00e9ho nejen ztr\u00e1tou kon\u010detiny, ale sou\u010dasn\u011b m\u00e1 toto onemocn\u011bn\u00ed vysokou mortalitu. U nemocn\u00fdch s kritickou kon\u010detinovou ischemi\u00ed s difuzn\u00edm posti\u017een\u00edm arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b b\u00e9rce je 5let\u00e9 p\u0159e\u017eit\u00ed35% a 10let\u00e9 8%.<\/li>\n<li style=\"text-align: justify;\"><strong>P\u0159\u00edznaky<br \/>\n<\/strong>Projevy jsou z\u00e1visl\u00e9 na rozsahu posti\u017een\u00ed; nap\u0159. \u00fapln\u00fd uz\u00e1v\u011br jedn\u00e9 b\u00e9rcov\u00e9 arterie p\u0159i sou\u010dasn\u00e9m norm\u00e1ln\u00edm n\u00e1lezu na ostatn\u00edch arteri\u00edch a p\u0159i dobr\u00e9m p\u0159\u00edtoku se v\u016fbec nemus\u00ed projevit. V\u011bt\u0161inou se v\u0161ak jedn\u00e1 o kombinaci hemodynamicky v\u00fdznamn\u00fdch sten\u00f3z a uz\u00e1v\u011br\u016f v\u0161ech 3 arteri\u00ed, \u010dasto v kombinaci s uz\u00e1v\u011brem AFS nebo AP. Nemocn\u00ed maj\u00ed nejenom klaudikace, ale tak\u00e9 klidov\u00e9 bolesti a nekr\u00f3zy.<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<br \/>\n<\/strong>Jedn\u00e1 se o vysoce rizikovou skupinu nemocn\u00fdch,kdy krom\u011b obvykl\u00fdch vy\u0161et\u0159en\u00ed je t\u0159eba se zam\u011b\u0159it na doprovodn\u00e1 onemocn\u011bn\u00ed \u2013 srde\u010dn\u00ed, mozkov\u00e1 a ledvinn\u00e1. Po fyzik\u00e1ln\u00edch vy\u0161et\u0159en\u00edch lze nemocn\u00e9ho do\u0161et\u0159it barevnou duplexn\u00ed sonografi\u00ed, ale p\u0159ed p\u0159edpokl\u00e1dan\u00fdm v\u00fdkonem je nutn\u00e1 n\u011bkter\u00e1 z angiografick\u00fdch forem. V\u0161echny formy UZ vy\u0161et\u0159en\u00ed jsou z chirugick\u00e9ho hlediska vhodn\u011bj\u0161\u00ed ke kontrole a monitoraci n\u00e1lezu po chirurgick\u00e9m nebo endovaskul\u00e1rn\u00edm v\u00fdkonu<i>.<\/i><\/li>\n<li style=\"text-align: justify;\"><strong>NMR ag<\/strong>\n<ul>\n<li style=\"text-align: justify;\">0 Neinvazivn\u00ed metoda s vysokou senzitivitou a specifitou n\u00e1lezu, kdy se kontrastn\u00ed l\u00e1tka(gadolinium) pod\u00e1v\u00e1 intraven\u00f3zn\u011b. Zhodnot\u00ed lokalizaci a rozsah sten\u00f3z a uz\u00e1v\u011br\u016f nejenom v b\u00e9rcov\u00e9 et\u00e1\u017ei, ale cel\u00e9 aort\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b od br\u00e1nice dist\u00e1ln\u011b. V\u00fdhody a nev\u00fdhody metody jsou pops\u00e1ny v\u00fd\u0161e. Je nezbytn\u00e1 p\u0159ed zv\u00e1\u017een\u00edm chirurgick\u00e9 nebo endovaskul\u00e1rn\u00ed intervence. Je vhodn\u00e1 k poopera\u010dn\u00ed kontrole.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>CT ag<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Neinvazivn\u00ed metoda v podstat\u011b se stejnou v\u00fdt\u011b\u017enost\u00ed jako NMR ag; je z\u0159ejm\u00e1 radia\u010dn\u00ed z\u00e1t\u011b\u017e.Na mnoha pracovi\u0161t\u00edch je dostupn\u011bj\u0161\u00ed ne\u017e NMRag. Je pou\u017eiteln\u00e1 v situac\u00edch, kdy je NMR ag kon-traindikov\u00e1no.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Intraarteri\u00e1ln\u00ed DSA<\/strong>\n<ul>\n<li style=\"text-align: justify;\">0 Jedn\u00e1 se o invazivn\u00ed metodu se zn\u00e1m\u00fdmi riziky, kter\u00e1 v\u0161ak poskytuje nejkvalitn\u011bj\u0161\u00ed zobrazen\u00edb\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b. Je dnes ur\u010dena pro situace ke zhodnocen\u00ed nejasn\u00fdch n\u00e1lez\u016f p\u0159edchoz\u00edch metod a umo\u017e\u0148uje ihned nav\u00e1zat endovaskul\u00e1rn\u00edm v\u00fdkonem.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Indikace k v\u00fdkonu<\/strong><br \/>\nChronick\u00e9 uz\u00e1v\u011bry poplite\u00e1ln\u00edho a b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b, kter\u00e9 se projevuj\u00ed stadiem III nebo IV dle Fontaina jsou jasnou indikac\u00ed k chirurgick\u00e9mu nebo endovaskul\u00e1rn\u00edmu v\u00fdkonu. V podstat\u011b nejsou kontraindikac\u00ed ani pokro\u010dil\u00e9 kalcifikace na v\u00fdtokov\u00e9m traktu. V\u00fdrazn\u011b v\u0161ak zhor\u0161uj\u00ed v\u00fdsledky l\u00e9\u010dby. P\u0159i zva\u017eov\u00e1n\u00ed indikace je t\u0159eba zn\u00e1t mo\u017enosti chirurgick\u00fdch a endovaskul\u00e1rn\u00edch metod a v p\u0159\u00edpad\u011b pokro\u010dil\u00fdch perifern\u00edch nekrotick\u00fdch zm\u011bn zv\u00e1\u017eit prim\u00e1rn\u00ed amputaci. Nen\u00ed-li amputace indikov\u00e1na,p\u0159ich\u00e1z\u00ed v \u00favahu konzervativn\u00ed terapie.U nemocn\u00fdch ve stadiu II se jen vyj\u00edme\u010dn\u011b indikuje rekonstruk\u010dn\u00ed nebo endovaskul\u00e1rn\u00ed v\u00fdkon, indikace je klaudika\u010dn\u00ed interval pod 100 m, kter\u00fd nemocn\u00e9ho v\u00fdznamn\u011b limituje. Dle n\u00e1lezu m\u00e1 p\u0159ednost endovaskul\u00e1rn\u00ed terapie.<\/li>\n<li style=\"text-align: justify;\"><strong>Terapie<\/strong><\/li>\n<li style=\"text-align: justify;\">V\u011bt\u0161inou je indikov\u00e1na kombinace medikament\u00f3zn\u00ed (a fyzik\u00e1ln\u00ed), endovaskul\u00e1rn\u00ed a chirurgick\u00e9 terapie. Z\u00e1sadn\u00edm p\u0159edpokladem pro \u00fasp\u011b\u0161nou invazivn\u00ed l\u00e9\u010dbu onemocn\u011bn\u00ed b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b je vy\u0159e\u0161en\u00ed krevn\u00edho p\u0159\u00edtoku z vy\u0161\u0161\u00edch parti\u00ed. O\u0161et\u0159en\u00ed sten\u00f3z a uz\u00e1v\u011br\u016f vy\u0161\u0161\u00edch et\u00e1\u017e\u00ed lze prov\u00e9st simult\u00e1nn\u011b nebo dvoudob\u011b.<\/li>\n<li style=\"text-align: justify;\"><strong>Konzervativn\u00ed l\u00e9\u010dba<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Jako samostatn\u00e1 je opodstatn\u011bn\u00e1 u nemocn\u00fdch ve stadiu F II, k n\u00ed se p\u0159ipojuje z\u00e1kaz kou\u0159en\u00eda fyzik\u00e1ln\u00ed l\u00e9\u010dba. Ve stadiu F III a F IV m\u00e1 samo-statn\u00e1 l\u00e9\u010dba indikaci jen v p\u0159\u00edpad\u011b, \u017ee invazivn\u00edmetody jsou vylou\u010deny a od konzervativn\u00ed tera-pie se o\u010dek\u00e1v\u00e1 odd\u00e1len\u00ed amputace.<\/li>\n<li style=\"text-align: justify;\">Z prepar\u00e1t\u016f ur\u010den\u00fdch ke vasodilata\u010dn\u00ed konzervativn\u00ed terapii m\u00e1 smysl jen terapie prostaglandiny.P\u0159ipojuje se antiagrega\u010dn\u00ed l\u00e9\u010dba.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Endovaskul\u00e1rn\u00ed l\u00e9\u010dba<br \/>\n<\/strong>Endovaskul\u00e1rn\u00ed l\u00e9\u010dba b\u00e9rcov\u00e9ho \u0159e\u010di\u0161t\u011b je ur\u010dena nemocn\u00fdm ve stadiu F III a F IV. Toutometodou lze o\u0161et\u0159it i mnoho\u010detn\u00e9 sten\u00f3zy a jeur\u010dena p\u0159edev\u0161\u00edm pro nemocn\u00e9 vysok\u00e9ho v\u011bkua pro nemocn\u00e9 s komorbiditami. Rozvoj endo-vaskul\u00e1rn\u00edch technik umo\u017e\u0148uje vyu\u017eit\u00ed stent\u016fv t\u00e9to indikaci. Po dvou letech je pr\u016fchodnosto\u0161et\u0159en\u00fdch arteri\u00ed ve 40\u201350%, kon\u010detina jezachov\u00e1na v 85% p\u0159\u00edpad\u016f, ale ve sledovan\u00e9mobdob\u00ed 45% nemocn\u00fdch zem\u0159e na jin\u00e9 one-mocn\u011bn\u00ed. Vzhledem k relativn\u011b mal\u00e9 invazivit\u011bve srovn\u00e1n\u00ed s chirurgick\u00fdm v\u00fdkonem je indiko-v\u00e1na p\u0159ed chirurgickou l\u00e9\u010dbou.<\/li>\n<li style=\"text-align: justify;\"><strong>Chirurgick\u00e1 l\u00e9\u010dba<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Jedn\u00e1 se o celou \u0159adu variant bypassov\u00fdch operac\u00ed. Z\u00e1sadn\u00edm po\u017eadavkem je pou\u017eit\u00ed autolog-n\u00edho \u017eiln\u00edho materi\u00e1lu k rekonstrukci.\n<ul>\n<li style=\"text-align: justify;\">Femorocrur\u00e1ln\u00ed (-ped\u00e1ln\u00ed) bypass je typick\u00e1 rekonstrukce, kdy p\u0159\u00edtokem je spole\u010dn\u00e1 fe-mor\u00e1ln\u00ed arterie, v\u00fdtok je realizov\u00e1n n\u011bkterouz b\u00e9rcov\u00fdch arteri\u00ed a k bypassu se pou\u017eijeautologn\u00ed \u017e\u00edla (viz kapitola o c\u00e9vn\u00edch n\u00e1hra-d\u00e1ch). V indikaci kritick\u00e9 kon\u010detinov\u00e9 ische-mie m\u00e1 \u017e\u00edla 5letou pr\u016fchodnost a\u017e v 80% sezachov\u00e1n\u00edm kon\u010detiny v 80\u201390% p\u0159\u00edpad\u016f.<\/li>\n<li style=\"text-align: justify;\">Popliteo-crur\u00e1ln\u00ed bypass: p\u0159\u00edtokem je poplite\u00e1ln\u00ed arterie, v\u00fdhodou je p\u0159i jej\u00ed pr\u016fchodnosti,\u017ee \u017eiln\u00ed bypass je v\u00fdrazn\u011b krat\u0161\u00ed.<\/li>\n<li style=\"text-align: justify;\">Popliteo-ped\u00e1ln\u00ed bypass: p\u0159\u00edtokem je poplite\u00e1ln\u00ed arterie, v\u00fdtokov\u00fd trakt je ATP a ATA pod\u00farovn\u00ed hlezenn\u00e9ho kloubu. Je p\u0159ekvapuj\u00edc\u00ed,\u017ee arterie maj\u00ed v et\u00e1\u017ei nohy \u010dasto jen mal\u00e9sklerotick\u00e9 zm\u011bny.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Je z\u0159ejm\u00e9, \u017ee u v\u0161ech nemocn\u00fdch nen\u00ed dostupn\u00fd autologn\u00ed \u017eiln\u00ed materi\u00e1l. Jako n\u00e1hrada p\u0159ich\u00e1z\u00edv \u00favahu um\u011bl\u00e1 c\u00e9vn\u00ed prot\u00e9za. Jej\u00ed nev\u00fdhodou jerelativn\u00ed \u201etuhost\u201c jej\u00ed st\u011bny, a t\u00edm na\u0161it\u00ed k b\u00e9rco-v\u00e9 arterii (nedostate\u010dn\u00e1 compliance, compliancemismatch), a d\u00e1le jej\u00ed nevhodnost pro infikovan\u00fd ter\u00e9n. Prvn\u00ed v\u00fdhrada se \u0159e\u0161\u00ed pomoc\u00ed tzv. kompozitn\u00edho graftu, kde centr\u00e1ln\u00ed \u00fasek bypassu je tvo\u0159en ePTFE prot\u00e9zou a na ni navazuje aspo\u0148 minim\u00e1ln\u00ed \u017eiln\u00ed \u00fasek, kter\u00fd se potom anastomozuje ke stran\u011b p\u0159\u00edjmov\u00e9 arterie.<\/li>\n<li style=\"text-align: justify;\">Ke zlep\u0161en\u00ed pr\u016ftoku na periferii kon\u010detiny sn\u00ed\u017een\u00edm perifern\u00edho c\u00e9vn\u00edho odporu se p\u0159ipojuje lumb\u00e1ln\u00ed sympatektomie. V\u00fdkon nem\u00e1 velk\u00fd smysl u diabetik\u016f, proto\u017ee p\u0159i jejich onemocn\u011bn\u00ed do\u0161lo neuropatick\u00e9 sympatikol\u00fdze. Sou\u010dasn\u011b je u t\u011bchto nemocn\u00fdch v\u00fdrazn\u00e1 skler\u00f3za medie a c\u00e9vn\u00ed st\u011bna nereaguje na nervov\u00e9 podn\u011bty.<\/li>\n<li style=\"text-align: justify;\">Lumb\u00e1ln\u00ed sympatektomie\n<ul>\n<li style=\"text-align: justify;\">Sympatick\u00e1 inervace doln\u00edch kon\u010detin je zaji\u0161t\u011bna ganglii L1\u2013L4. Pro v\u011bt\u0161inu klinick\u00fdch indikac\u00ed je dostate\u010dn\u00e9 vyjmut\u00ed L2 a L3. Po jejich exstirpaci jsou p\u0159eru\u0161ena vasokonstri\u010dn\u00ed vl\u00e1kna pro doln\u00ed kon\u010detinu. Dojde k vasodilataci k\u016f\u017ee p\u0159edev\u0161\u00edm v d\u016fsledku otev\u0159en\u00ed ko\u017en\u00edch arterioven\u00f3zn\u00edch spojek, zlep\u0161en\u00ed prokrven\u00ed sval\u016f je jen kr\u00e1tkodob\u00e9. Nemocn\u00fd vn\u00edm\u00e1 vasodilataci pozitivn\u011b, ale schopnost zat\u00ed\u017een\u00ed kon\u010detiny se nem\u011bn\u00ed. Lumb\u00e1ln\u00ed sympatektomie jako samostatn\u00fd v\u00fdkon je trvale diskutov\u00e1na, jej\u00ed p\u0159\u00ednos jako sou\u010d\u00e1st rekonstruk\u010dn\u00edho v\u00fdkonu je akceptov\u00e1n.<\/li>\n<li style=\"text-align: justify;\">Sympatektomie se dnes v\u011bt\u0161inou prov\u00e1d\u00ed jako tzv. chemick\u00e1 sympatektomie infiltraci sympatick\u00fdch gangli\u00ed alkoholem nebo fenolem. Poloha gangli\u00ed se ur\u010duje radiologicky. Otev\u0159en\u00e1 sympatektomie je o\u0161et\u0159en\u00ed sympatick\u00fdch gangli\u00ed chirurgickou cestou retroperitoen\u00e1ln\u00edm nebotransabdomin\u00e1ln\u00edm p\u0159\u00edstupem. Sympatektomiilze tak\u00e9 prov\u00e9st laparoskopickou technikou.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">M\u00ed\u0161n\u00ed stimulace (neuromodulace)\n<ul>\n<li style=\"text-align: justify;\">Alternativou k \u010dist\u011b konzervativn\u00ed terapii nebo k prim\u00e1rn\u00ed amputaci je epidur\u00e1ln\u00ed m\u00ed\u0161n\u00ed stimulace. Doch\u00e1z\u00ed ke zlep\u0161en\u00ed mikrocirkulace a sn\u00ed-\u017een\u00ed bolestivosti. V n\u011bkter\u00fdch p\u0159\u00edpadech dojde ke zhojen\u00ed ulcerac\u00ed a m\u016f\u017ee doj\u00edt ke sn\u00ed\u017een\u00ed po\u010dtu amputac\u00ed. Limituj\u00edc\u00edm faktorem jsou vysok\u00e9 n\u00e1klady t\u00e9to l\u00e9\u010dby.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">N\u00e1sledn\u00e1 p\u00e9\u010de\n<ul>\n<li style=\"text-align: justify;\">Je t\u0159eba trvat na z\u00e1kazu kou\u0159en\u00ed. Nezbytn\u00e1 je l\u00e9\u010dba antiagrega\u010dn\u00ed (ev. du\u00e1ln\u00ed antiagregace), u \u017eiln\u00edch bypass\u016f je vhodn\u00e1 l\u00e9\u010dba antikoagula\u010dn\u00ed.Pr\u016fchodnost bypassu nebo v\u00fdsledky endovaskul\u00e1rn\u00ed terapie je t\u0159eba monitorovat klinicky, UZa dle pot\u0159eby angiograficky. P\u0159i progresi n\u00e1lezu je indikov\u00e1na endovaskul\u00e1rn\u00ed nebo chirugick\u00e1 terapie. Je prok\u00e1z\u00e1no, \u017ee tento postup (reinter-vence) je nakonec lacin\u011bj\u0161\u00ed ne\u017e p\u00e9\u010de o amputovan\u00e9ho nemocn\u00e9ho.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3>4.3 Akutn\u00ed a chronick\u00fd uz\u00e1v\u011br mesenteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b<\/h3>\n<h6>AKUTN\u00cd ST\u0158EVN\u00cd ISCHEMIE<\/h6>\n<p style=\"text-align: justify;\">Mesenteri\u00e1ln\u00ed infarkt je n\u00e1hl\u00e1 p\u0159\u00edhoda b\u0159i\u0161n\u00ed, kter\u00e1 m\u00e1 letalitu 60\u201380%. Jej\u00ed problematika spo\u010d\u00edv\u00e1 v obt\u00ed\u017en\u00e9 diagnostice a v razanci tk\u00e1\u0148ov\u00e9ho po\u0161kozen\u00ed ischemi\u00ed. Vyskytuje se asi 1\u20132% nemocn\u00fdch s n\u00e1hlou p\u0159\u00edhodou b\u0159i\u0161n\u00ed, s p\u0159ib\u00fdvaj\u00edc\u00edm v\u011bkem nemocn\u00fdch jeho frekvence nar\u016fst\u00e1.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Symptomatologie<\/li>\n<li style=\"text-align: justify;\">Typick\u00fd obraz akutn\u00edho arteri\u00e1ln\u00ed uz\u00e1v\u011bru prob\u00edh\u00e1 ve 3 f\u00e1z\u00edch:\n<ul>\n<li style=\"text-align: justify;\">Inici\u00e1ln\u00ed (0\u20136 hod) \u2013 krut\u00e9 bolesti b\u0159icha, \u0161ok, pr\u016fjem.<\/li>\n<li style=\"text-align: justify;\">Stadium klidu (7\u201312 hod) \u2013 tup\u00e9 bolesti b\u0159icha, st\u0159evn\u00ed par\u00e9za, zhor\u0161en\u00ed celkov\u00e9ho stavu.<\/li>\n<li style=\"text-align: justify;\">Termin\u00e1ln\u00ed stadium (12\u201324 hod) \u2013 ileus, peritonitida, sepse, multiorg\u00e1nov\u00e9 selh\u00e1n\u00ed.Mo\u017enost \u00fa\u010deln\u011b zas\u00e1hnout a dos\u00e1hnout akceptovateln\u00fdch v\u00fdsledk\u016f je jen p\u0159i rychl\u00e9 diagn\u00f3ze inici\u00e1ln\u00edho stadia. Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou (85%) je uz\u00e1v\u011br horn\u00ed mesenterick\u00e9 arterie (AMS). AMS je hlavn\u00ed vy\u017eivuj\u00edc\u00ed arteri\u00ed st\u0159eva, ale mo\u017enost jej\u00edho kolater\u00e1ln\u00edho ob\u011bhu je minim\u00e1ln\u00ed (na rozd\u00edl od truncus coeliacus a a. mesenterica inferior). P\u0159i akutn\u00ed uz\u00e1v\u011bru AMS vznikne prakticky v\u017edy mesenteri\u00e1ln\u00ed infarkt. P\u0159\u00ed\u010dinou akutn\u00edho uz\u00e1v\u011bru AMS je v 34% arteri\u00e1ln\u00ed tromb\u00f3za, v 31% embolizace. Neokluzivn\u00ed ischemie (hypoperfuze p\u0159i kardi\u00e1ln\u00edm selh\u00e1v\u00e1n\u00ed, stavu po IM, stav po kardiochirurgick\u00fdch v\u00fdkonech s vasopresory, \u010dist\u00fd arteri\u00e1ln\u00ed spazmus p\u0159i kokainismu nebo ergotaminov\u00e9 intoxikaci) tvo\u0159\u00ed asi 25%. Ven\u00f3zn\u00ed mesenteri\u00e1ln\u00ed tromb\u00f3za se vyskytuje asi v 8% a m\u00e1 prolongovan\u00fd pr\u016fb\u011bh.Pro stanoven\u00ed diagn\u00f3zy t\u00e9to NPB je z\u00e1sadn\u00ed c\u00edlen\u00e1 kardiovaskul\u00e1rn\u00ed anamn\u00e9za a p\u0159i hodnocen\u00ed pot\u00ed\u017e\u00ed myslet na mo\u017enost akutn\u00edho c\u00e9vn\u00edho uz\u00e1v\u011bru.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<\/strong><\/li>\n<li style=\"text-align: justify;\">Nejv\u00fdt\u011b\u017en\u011bj\u0161\u00ed metodou je CT ag b\u0159icha, kter\u00e1 nejp\u0159esn\u011bji zhodnot\u00ed n\u00e1lez na mesenteri\u00e1ln\u00edch arteri\u00edch a sou\u010dasn\u011b tak\u00e9 celkov\u00fd b\u0159i\u0161n\u00ed n\u00e1lez. P\u0159i po-dez\u0159en\u00ed na uz\u00e1v\u011br je indikov\u00e1na transfemor\u00e1ln\u00ed in-traarteri\u00e1ln\u00ed DSA, kter\u00e1 umo\u017en\u00ed definitivn\u00ed p\u0159esn\u00e9 zhodnocen\u00ed c\u00e9vn\u00edho svazku a m\u016f\u017ee b\u00fdt pou\u017eita k l\u00e9\u010db\u011b metodami interven\u010dn\u00ed radiologie (trombol\u00fdzy, trombembolektomie, stent-PTA). Z\u00e1sadn\u00ed informace jsou: jedn\u00e1 se o arteri\u00e1ln\u00ed nebo \u017eiln\u00ed uz\u00e1v\u011br, jedn\u00e1 se uz\u00e1v\u011br hlavn\u00edho kmene nebo periferie,etiologie (tromb\u00f3za, embolie, neokluzivn\u00ed proces).Z laboratorn\u00edch vy\u0161et\u0159en\u00ed je nejp\u0159\u00ednosn\u011bj\u0161\u00ed hodnota(resp. sledov\u00e1n\u00ed hladiny \u2013 vzestup) lakt\u00e1tu v s\u00e9ru nad 4 mmol\/l, ostatn\u00ed parametry jsou nespecifick\u00e9: leukocyt\u00f3za, CRP, acid\u00f3za.<\/li>\n<li style=\"text-align: justify;\"><strong>Indikace a terapie<br \/>\n<\/strong>V\u00fdkon, kter\u00fd obnov\u00ed prokrven\u00ed st\u0159eva, m\u00e1 absolutn\u00ed prioritu. Vy\u0161et\u0159ovac\u00ed metody mohou stanovit diagn\u00f3zu, ale mohou b\u00fdt p\u0159\u00ed\u010dinou pozdn\u00edho o\u0161et\u0159en\u00ed.Diagnostick\u00e1 laparotomie je obhajiteln\u00e1 p\u0159i pode-z\u0159en\u00ed na c\u00e9vn\u00ed uz\u00e1v\u011br p\u0159edev\u0161\u00edm v situac\u00edch, kdy nen\u00ed kvalitn\u00ed vy\u0161et\u0159ovac\u00ed komplement k dispozici.<\/li>\n<li style=\"text-align: justify;\">B\u011bhem vy\u0161et\u0159ov\u00e1n\u00ed je indikov\u00e1na antikoagula\u010dn\u00ed terapie (bolus heparinu 5000 IU), zaveden\u00ed centr\u00e1ln\u00edho \u017eiln\u00edho kat\u00e9tru, stabilizace ob\u011bhu, pod\u00e1n\u00ed \u0161irokospektr\u00fdch antibiotik a analgetick\u00e1 terapie.<\/li>\n<li style=\"text-align: justify;\">U nemocn\u00fdch, kdy byla dg. stanovena intraarteri\u00e1ln\u00ed DSA, lze kat\u00e9trem podat prostaglandin a heparink farmakologick\u00e9mu ovlivn\u011bn\u00ed pr\u016ftoku. Indikac\u00ed jsou neokluzivn\u00ed ischemie a perifern\u00ed c\u00e9vn\u00ed uz\u00e1v\u011bry bez peritonitidy.<\/li>\n<li style=\"text-align: justify;\">Z chirurgick\u00e9ho hlediska je p\u0159i stanoven\u00ed indikace k opera\u010dn\u00edmu v\u00fdkonu z\u00e1sadn\u00ed, zda je nebo nen\u00ed p\u0159\u00edtomn\u00fd obraz peritonitidy. U nemocn\u00fdch bez peritonitidy rozhoduje angiografie, zda bude provede-na laparotomie nebo zda bude l\u00e9\u010dba konzervativn\u00ed.P\u0159i obrazu peritonitidy je prakticky v\u017edy indikov\u00e1na laparotomie. Jen u moribudn\u00edch nemocn\u00fdch je mo\u017en\u00e9 ji odm\u00edtnout. Z \u010dist\u011b c\u00e9vn\u00edho hlediska je p\u0159i centr\u00e1ln\u00edm uz\u00e1v\u011bru indikov\u00e1na revaskularizace, p\u0159i perifern\u00edm uz\u00e1v\u011bru fibrinolytick\u00e1 nebo farmakologick\u00e1 l\u00e9\u010dba. Z\u00e1sadn\u00ed je n\u00e1lez na st\u0159ev\u011b. P\u0159i gangr\u00e9n\u011b je indikov\u00e1na resekce, u velmi pokro\u010dil\u00fdch n\u00e1lez\u016f opera\u010dn\u00ed v\u00fdkon kon\u010d\u00ed jen explorac\u00ed. P\u0159i poru\u0161en\u00e9 vitalit\u011b st\u0159eva (nen\u00ed z\u0159ejm\u00e1 jednozna\u010dn\u011b gangr\u00e9na)je indikov\u00e1na revaskularizace v kombinac\u00ed s parci\u00e1ln\u00ed resekc\u00ed st\u0159eva. Tyto v\u00fdkony, kde je nejist\u00fd v\u00fdsledek opera\u010dn\u00edho v\u00fdkonu, vy\u017eaduj\u00ed dal\u0161\u00ed kontroly intraabdomin\u00e1ln\u00edho n\u00e1lezu (second look).<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00fd postup lze shrnout: laparotomie p\u0159i obrazu peritonitidy, pokud je pro nemocn\u00e9ho opera\u010dn\u00ed v\u00fdkon v\u016fbec \u00fanosn\u00fd. U centr\u00e1ln\u00edch uz\u00e1v\u011br\u016f je indikov\u00e1na c\u00e9vn\u00ed rekonstrukce. Je indikov\u00e1na resekce z\u0159eteln\u011b avit\u00e1ln\u00edch \u00fasek\u016f st\u0159eva.<\/li>\n<li style=\"text-align: justify;\">O\u0161et\u0159en\u00ed mesenteri\u00e1ln\u00edch arteri\u00ed vy\u017eaduje vysoce zku\u0161en\u00e9ho chirurga, proto\u017ee jejich preparace prob\u00edh\u00e1 v technicky n\u00e1ro\u010dn\u00e9m ter\u00e9nu. Principi\u00e1ln\u011b se jedn\u00e1 o trombembolektomie z arteriotomie, kter\u00e1 se uzav\u0159e p\u0159\u00edmo nebo pomoc\u00ed patchplastiky.<\/li>\n<li style=\"text-align: justify;\">Z rozvojem endovaskul\u00e1rn\u00edch metod p\u0159ich\u00e1z\u00ed v \u00favahu o\u0161et\u0159en\u00ed uz\u00e1v\u011br\u016f pomoc\u00ed aspira\u010dn\u00ed trombembolektomie pomoc\u00ed transfemor\u00e1ln\u011b zaveden\u00e9ho kat\u00e9tru nebo trombol\u00fdza.<\/li>\n<li style=\"text-align: justify;\">P\u0159i resekci st\u0159eva je t\u0159eba v\u011bd\u011bt, \u017ee posti\u017een\u00ed sliznice je v\u017edy ve v\u011bt\u0161\u00edm rozsahu ne\u017e posti\u017een\u00ed zevn\u00edch vrstev (tunica muscularis, ser\u00f3za) st\u0159evn\u00ed st\u011bny, proto resekce mus\u00ed zasahovat daleko do zdrav\u00e9 tk\u00e1n\u011b. Anastom\u00f3za ve \u0161patn\u011b zhodnocen\u00e9m ischemick\u00e9m \u00faseku vede k jej\u00edmu rozpadu a ke vzniku peritonitidy. Je t\u0159eba tak\u00e9 zhodnotit ponechan\u00fd \u00fasek tenk\u00e9ho st\u0159eva, pokud je m\u00e9n\u011b ne\u017e 70\u2013100 cm, je p\u0159edpoklad vzniku syndromu kr\u00e1tk\u00e9ho st\u0159eva. U v\u0161ech v\u00fdkon\u016f, kdy nen\u00ed jist\u00e1 poopera\u010dn\u00ed vitalita st\u0159eva nebo p\u0159etrv\u00e1v\u00e1 obraz peritonitidy, je indikov\u00e1n za 8\u201312 hodin second look. Jedn\u00e1 se o dal\u0161\u00ed kontroln\u00ed laparotomii, kter\u00e1 zhodnot\u00ed aktu\u00e1ln\u00ed n\u00e1lez v dutin\u011b peritone\u00e1ln\u00ed.<\/li>\n<li style=\"text-align: justify;\">Nemocn\u00fd je po \u00fasp\u011b\u0161n\u00e9m o\u0161et\u0159en\u00ed ohro\u017een reperfuzn\u00edm syndromem: uvoln\u011bn\u00e9 metabolity, bakterie a toxiny mohou po\u0161kodit dal\u0161\u00ed org\u00e1ny a b\u00fdt p\u0159\u00ed\u010dinou multiorg\u00e1nov\u00e9ho selh\u00e1n\u00ed.<\/li>\n<\/ul>\n<h6>CHRONICK\u00c9 STEN\u00d3ZUJ\u00cdC\u00cd PROCESY A UZ\u00c1V\u011aRY INTESTIN\u00c1LN\u00cdCH ARTERI\u00cd<\/h6>\n<p style=\"text-align: justify;\">Jsou spojeny s nar\u016fstaj\u00edc\u00edm v\u011bkem populace a kardiovaskul\u00e1rn\u00ed morbiditou. U 98% nemocn\u00fdch vznikaj\u00ed na aterosklerotick\u00e9m podklad\u011b. Jsou \u010dasto n\u00e1hodn\u00fdm n\u00e1lezem. Jejich klinick\u00e9 projevy se ozna\u010duj\u00ed jako abdomin\u00e1ln\u00ed ang\u00edna. Asi 5% nemocn\u00fdch s nejasn\u00fdmi bolestmi b\u0159icha m\u00e1 pot\u00ed\u017ee vyvolan\u00e9 ischemick\u00fdmi zm\u011bnami. Postupn\u011b se vyv\u00edjej\u00edc\u00ed sten\u00f3zy hlavn\u00edch kmen\u016f umo\u017e\u0148uj\u00ed rozvoj kolater\u00e1ln\u00edho ob\u011bhu. Pot\u00ed\u017ee vznikaj\u00ed a\u017e p\u0159i posti\u017een\u00ed dvou hlavn\u00edch kmen\u016f hemodynamicky v\u00fdznamn\u00fdmi sten\u00f3zami nebo uz\u00e1v\u011brem. Typick\u00fdm m\u00edstem vzniku sten\u00f3z je odstup mesenterick\u00e9 arterie z aorty. Vzd\u00e1len\u00e9 nebo dlouh\u00e9 sten\u00f3zy jsou lokalizov\u00e1ny perifern\u011bji, jsou vz\u00e1cn\u011bj\u0161\u00ed a jsou spojov\u00e1ny s metabolick\u00fdmi chorobami jako diabetes mellitus, chronick\u00e1 ledvinn\u00e1 nedostate\u010dnost, amyloid\u00f3za. Tyto sten\u00f3zy br\u00e1n\u00ed vzniku \u00fa\u010dinn\u00e9ho kolater\u00e1ln\u00edho ob\u011bhu.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Symptomatologie<br \/>\n<\/strong>Lze ji dob\u0159e srovnat s ischemi\u00ed doln\u00edch kon\u010detin dle Fontaina: I. asymptomatick\u00e9, II. intermitentn\u00edbolesti \u2013 angina abdominalis, III. klidov\u00e9 b\u0159i\u0161n\u00ed bolesti, IV. ischemick\u00e9 org\u00e1nov\u00e9 l\u00e9ze \u2013 infarkt.<\/li>\n<li style=\"text-align: justify;\">Klasick\u00e1 symptomatologick\u00e1 tri\u00e1da se skl\u00e1d\u00e1 z bolest\u00ed b\u0159icha, v\u00e1hov\u00e9ho poklesu a paraumbilik\u00e1ln\u00edhoc\u00e9vn\u00edho \u0161elestu. Bolesti b\u0159icha jsou postprandi\u00e1ln\u00ed,vznikaj\u00ed asi 20 minut po j\u00eddle a mohou trvat i n\u011bkolik hodin. Onemocn\u011bn\u00ed vede k v\u00fdrazn\u00e9mu v\u00e1hov\u00e9mu \u00fabytku a sn\u00ed\u017een\u00ed celkov\u00e9 v\u00fdkonnosti. Ischemieje spojena se vznikem chronick\u00fdch z\u00e1n\u011btliv\u00fdch onemocn\u011bn\u00ed GIT (gastroduoden\u00e1ln\u00ed v\u0159ed).<\/li>\n<li style=\"text-align: justify;\"><strong>Diagnostika<br \/>\n<\/strong>K pr\u016fkazu chronick\u00e9 st\u0159evn\u00ed ischemie neexistuj\u00ed specifick\u00e9 laboratorn\u00ed testy, v diagnostice je z\u00e1sad-n\u00ed vy\u0161et\u0159en\u00ed pomoc\u00ed barevn\u00e9 duplexn\u00ed sonografie,kter\u00e1 zhodnot\u00ed rychlost tok\u016f \u2013 vysok\u00e9 rychlostinad 200cm\/s jsou obrazem poststenotick\u00fdch tok\u016f.Sonografii pova\u017eujeme za dobrou screeningovou metodu, ale indikace k dal\u0161\u00edmu \u0159e\u0161en\u00ed je stav\u011bna na zhodnocen\u00ed c\u00e9vn\u00edho svazku cestou CT ag, kdy jsou jednotliv\u00e9 \u0159ezy zpracov\u00e1ny ve 3D modu. P\u0159i nejasn\u00e9m n\u00e1lezu nebo p\u0159i pl\u00e1novan\u00e9m endovaskul\u00e1rn\u00edm v\u00fdkonu je indikov\u00e1na intraarteri\u00e1ln\u00ed DSA (fotogalerie 4e).<\/li>\n<li style=\"text-align: justify;\"><strong>Indikace a terapie<br \/>\n<\/strong>Indikace k v\u00fdkonu na arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti p\u0159i chronick\u00e9 st\u0159evn\u00ed ischemii mus\u00ed b\u00fdt zhodnocena z pohledu c\u00e9vn\u011b-chirurgick\u00e9ho a endovaskul\u00e1rn\u00edho.<br \/>\nNe\u00fasp\u011bch zvolen\u00e9 metody m\u016f\u017ee m\u00edt za d\u016fsledek definitivn\u00ed c\u00e9vn\u00ed uz\u00e1v\u011br s ischemi\u00ed st\u0159eva s let\u00e1ln\u00edm pr\u016fb\u011bhem. Ve stadiu I je relativn\u00ed indikac\u00ed k v\u00fdkonu na viscer\u00e1ln\u00ed arterii situace, kdy je opera\u010dn\u00ed v\u00fdkon indikov\u00e1n z jin\u00e9ho d\u016fvodu, nap\u0159. proaort\u00e1ln\u00ed aneuryzma. Asymptomatick\u00e9 stadium seneoperuje. Stadium II a III jsou absolutn\u00ed indikac\u00edk v\u00fdkonu.<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00e9 v\u00fdkony st\u00e1le p\u0159evl\u00e1daj\u00ed. Pokud jsou posti\u017eeny 2 arterie (truncus coeliacus a AMS), jeindikace k chirurgick\u00e9mu o\u0161et\u0159en\u00ed obou. V\u00fdkonna obou kmenech v\u00fdrazn\u011b sni\u017euje riziko pozdn\u00ed re-cidivy. P\u0159i nutnosti pou\u017e\u00edt interpon\u00e1t je indikov\u00e1naautologn\u00ed vena. Vlastn\u00ed opera\u010dn\u00ed v\u00fdkon je technicky n\u00e1ro\u010dn\u00fd, proto\u017ee jako p\u0159\u00edtok slou\u017e\u00ed subdiafragmatick\u00fd \u00fasek aorty. Krom\u011b bypassu je indikov\u00e1na trombendarterektomie jednotliv\u00fdch kmen\u016f.<\/li>\n<li style=\"text-align: justify;\">Endovaskul\u00e1rn\u00ed v\u00fdkony se prov\u00e1d\u011bj\u00ed transfemor\u00e1ln\u00ed nebo transbrachi\u00e1ln\u011b. Proti operaci je jejich v\u00fdhodou minim\u00e1ln\u00ed opera\u010dn\u00ed trauma (proti laparotomii). P\u0159evl\u00e1daj\u00ed angioplastiky hlavn\u00edch kmen\u016f v\u011bt\u0161inou se zaveden\u00edm stentu. Nemocn\u00ed jsou sledov\u00e1ni v kr\u00e1tk\u00fdch intervalech, proto\u017ee je vysok\u00fd stupe\u0148 recidiv (in stent stenosis).<\/li>\n<li style=\"text-align: justify;\">Komplikac\u00ed v\u00fdkon\u016f jsou poopera\u010dn\u00ed st\u0159evn\u00ed ischemie, kter\u00e9 jsou zp\u016fsobeny embolizacemi nebo di-sekc\u00ed c\u00e9vn\u00ed st\u011bny s n\u00e1slednou tromb\u00f3zou.<\/li>\n<li style=\"text-align: justify;\">V poopera\u010dn\u00edm obdob\u00ed je indikov\u00e1na antiagrega\u010dn\u00ed terapie. U nemocn\u00fdch s \u017eiln\u00edm bypassem je indikov\u00e1na terapie antikoagula\u010dn\u00ed warfarinem.<\/li>\n<\/ul>\n<h6 style=\"text-align: center;\">Fotogalerie 4e:<br \/>\nsten\u00f3za truncus coeliacus<\/h6>\n<div id=\"attachment_2119\" style=\"width: 510px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/4e.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2119\" class=\"size-large wp-image-2119 \" title=\"Fotogalerie 4e: sten\u00f3za truncus coeliacus\" alt=\"Fotogalerie 4e: sten\u00f3za truncus coeliacus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/4e-720x1024.png\" width=\"500\" height=\"711\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/4e-720x1024.png 720w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/4e-211x300.png 211w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/4e.png 2036w\" sizes=\"auto, (max-width: 500px) 100vw, 500px\" \/><\/a><p id=\"caption-attachment-2119\" class=\"wp-caption-text\">Fotogalerie 4e: sten\u00f3za truncus coeliacus<\/p><\/div>\n<p style=\"text-align: center;\">\n","protected":false},"excerpt":{"rendered":"<p>4.1 Akutn\u00ed kon\u010detinov\u00fd arteri\u00e1ln\u00ed uz\u00e1v\u011br (embolizace a tromb\u00f3za) \u00a0Jedn\u00e1 se n\u00e1hle vzniklou poruchu prokrven\u00ed (ischemii) kon\u010detiny, p\u0159i kter\u00e9 je bezprost\u0159edn\u011b ohro\u017eena viabilita kon\u010detiny. Nej\u010dast\u011bji b\u00fdv\u00e1 posti\u017eena jedna doln\u00ed kon\u010detina (85%), m\u00e9n\u011b \u010dasto jsou posti\u017eeny ob\u011b doln\u00ed kon\u010detiny nebo horn\u00ed kon\u010detina. Ischemie je zpo\u010d\u00e1tku reverzibiln\u00ed, pokud nen\u00ed o\u0161et\u0159ena dojde k ireverzibiln\u00edm zm\u011bn\u00e1m a gangr\u00e9n\u011b tk\u00e1n\u00ed. Stupe\u0148 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":20,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2031","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2031","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=2031"}],"version-history":[{"count":30,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2031\/revisions"}],"predecessor-version":[{"id":3862,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2031\/revisions\/3862"}],"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=2031"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}