{"id":2202,"date":"2013-04-07T11:30:30","date_gmt":"2013-04-07T11:30:30","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2202"},"modified":"2013-06-11T12:08:23","modified_gmt":"2013-06-11T12:08:23","slug":"6-chirurgicka-onemocneni-karotickeho-reciste","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2202","title":{"rendered":"6 Chirurgick\u00e1 onemocn\u011bn\u00ed karotick\u00e9ho \u0159e\u010di\u0161t\u011b"},"content":{"rendered":"<h6>KAROTICK\u00c9 \u0158E\u010cI\u0160T\u011a \u2013 OBLITERUJ\u00cdC\u00cd ATEROSKLER\u00d3ZA<\/h6>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00edm \u00fakolem l\u00e9\u010dby cerebrovaskul\u00e1rn\u00edch onemocn\u011bn\u00ed je zabr\u00e1nit c\u00e9vn\u00ed mozkov\u00e9 p\u0159\u00edhod\u011b (CMP). Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou je aterosklerotick\u00fd proces. Postaven\u00ed chirurga se v t\u00e9to problematice m\u011bn\u00ed a je z\u00e1visl\u00e9 na sou\u010dasn\u00fdch poznatc\u00edch patofyziologie procesu CMP, na dostupnosti zobrazovac\u00edch technik a na rozvoji chirurgick\u00fdch a endovaskul\u00e1rn\u00edch metod. Volba nejspr\u00e1vn\u011bj\u0161\u00ed metody podl\u00e9h\u00e1 v\u00fdsledk\u016fm cel\u00e9 \u0159ady studi\u00ed. V\u00fdznam chirurgick\u00e9ho v\u00fdkonu \u2013 karotick\u00e9 endarterektomie je st\u00e1le diskutov\u00e1n.<\/p>\n<p style=\"text-align: justify;\">CMP je ve vysp\u011bl\u00fdch zem\u00edch t\u0159et\u00ed nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou smrti. V\u00fdskyt CMP je u obou pohlav\u00ed toto\u017en\u00fd a nar\u016fst\u00e1 s p\u0159ib\u00fdvaj\u00edc\u00edm v\u011bkem. N\u00e1lezy prokazuj\u00ed, \u017ee 87% CMP je ischemick\u00fdch a 13% je vyvol\u00e1no subarachnoide\u00e1ln\u00edm a intracerebr\u00e1ln\u00edm krv\u00e1cen\u00edm. Ischemick\u00e9 p\u0159\u00edhody jsou zp\u016fsobeny aterosklerotick\u00fdmi zm\u011bnami extra nebo intrakrani\u00e1ln\u00edmi, kardioembolick\u00fdmi nebo lakun\u00e1rn\u00edmi zm\u011bnami.Sten\u00f3za karotick\u00e9ho \u0159e\u010di\u0161t\u011b se p\u0159i hodnocen\u00ed nemocn\u00fdch nez\u00e1visle na jejich v\u011bku (25\u201384 let) vyskytuje u 3,8% mu\u017e\u016f a 2,7% \u017een. Tato data se m\u011bn\u00ed (nar\u016fstaj\u00ed) s v\u011bkem nemocn\u00fdch. V\u00fdskyt cerebrovaskul\u00e1rn\u00edho onemocn\u011bn\u00ed je mnohem vy\u0161\u0161\u00ed u nemocn\u00fdch s ostatn\u00edmi projevy perifern\u00edch c\u00e9vn\u00edch onemocn\u011bn\u00ed.N\u00e1sledky CMP p\u0159edstavuj\u00ed z\u00e1va\u017enou osobn\u00ed a soci\u00e1ln\u00ed problematiku. 50% nemocn\u00fdch m\u00e1 hemipar\u00e9zu, 30% nen\u00ed schopno samostatn\u00e9 ch\u016fze, 19% m\u00e1 af\u00e1zii a 26% vy\u017eaduje trvalou soci\u00e1ln\u00ed p\u00e9\u010di.Rizikov\u00e9 faktory jsou stejn\u00e9 jako u ostatn\u00edch projev\u016f ateroskler\u00f3zy: v\u011bk, hypertenze, diabetes mellitus, kou\u0159en\u00ed a fibrilace s\u00edn\u00ed.Aterosklerotick\u00e9 posti\u017een\u00ed karotick\u00e9ho \u0159e\u010di\u0161t\u011b je predispozic\u00ed ke vzniku transientn\u00ed mozkov\u00e9 ataky (TIA) nebo c\u00e9vn\u00ed mozkov\u00e9 p\u0159\u00edhody (CMP). Riziko vzniku t\u011bchto projev\u016f je z\u00e1visl\u00e9 na rozsahu sklerotick\u00fdch zm\u011bn. Aterosklerotick\u00fd karotick\u00fd pl\u00e1t m\u00e1 sv\u016fj typick\u00fd v\u00fdvoj od infiltrace lipid\u016f do arteri\u00e1ln\u00ed st\u011bnypo vznik fibr\u00f3zn\u00edho pl\u00e1tu (plaku). Pro nemocn\u00e9ho p\u0159edstavuje riziko nejenom jeho r\u016fst, kter\u00fd vede ke z\u00fa\u017een\u00ed lumen arterie, ale p\u0159edev\u0161\u00edm krv\u00e1cen\u00ed do plaku, kdy pl\u00e1t n\u00e1hle zv\u011bt\u0161\u00ed sv\u016fj objem a sten\u00f3za se zv\u011bt\u0161\u00ed nebo dojde k uz\u00e1v\u011bru arterie. Na pl\u00e1tu vznikaj\u00ed drobn\u00e9 ruptury, postupn\u011b ulcerace, na kter\u00fdch vznikaj\u00ed tromby, kter\u00e9 spolu s drt\u00ed z pl\u00e1tu vedou k drobn\u00fdm embolizac\u00edm. Chov\u00e1n\u00ed pl\u00e1tu lze dob\u0159e monitorovat pomoc\u00ed UZ vy\u0161et\u0159en\u00ed, kter\u00e9 popisuje pomalu rostouc\u00ed stabiln\u00ed pl\u00e1ty, kter\u00e9 jsou m\u00e9n\u011b rizikov\u00e9 z hlediska TIA nebo CMP, a pl\u00e1ty nestabiln\u00ed, kter\u00e9 mohou v\u00e9st k n\u00e1hl\u00fdm a fat\u00e1ln\u00edm klinick\u00fdm projev\u016fm. Transientn\u00ed ischemick\u00e1 ataka (TIA) je definovan\u00e1 jako n\u00e1hle vznikl\u00e1 neurologick\u00e1 symptomatologie, kter\u00e1 trv\u00e1 m\u00e9n\u011b jak 24 hodin (v\u011bt\u0161inou jen n\u011bkolik minut) a nezanech\u00e1v\u00e1 trval\u00e9 n\u00e1sledky. P\u0159\u00ed\u010dinou TIA je mozkov\u00e1 hypoperfuze p\u0159i hemodynamicky v\u00fdznamn\u00e9 sten\u00f3ze karotidy nebo embolizace z exulcerovan\u00e9ho pl\u00e1tu. Projevy jsou pestr\u00e9: transientn\u00ed jednostrann\u00e9 poruchy zraku, poruchy mluvy nebo poruchy hybnosti.C\u00e9vn\u00ed mozkov\u00e1 p\u0159\u00edhoda (CMP) je infarkt centr\u00e1ln\u00edho nervov\u00e9ho syst\u00e9mu p\u0159i hypoperfuzi, embolizaci nebo krv\u00e1cen\u00ed. Projevy jsou velmi podobn\u00e9 jako p\u0159i TIA, ale jsou trval\u00e9.\u0158ada nemocn\u00fdch m\u00e1 aterosklerotick\u00e9 zm\u011bny v karotick\u00e9m \u0159e\u010di\u0161ti, ale nemaj\u00ed \u017e\u00e1dn\u00e9 p\u0159\u00edznaky \u2013 jedn\u00e1 se o asymptomatickou formu karotick\u00e9ho onemocn\u011bn\u00ed. Sledov\u00e1n\u00ed stavu karotick\u00e9ho \u0159e\u010di\u0161t\u011b pomoc\u00ed barevn\u00e9 duplexn\u00ed sonografie umo\u017en\u00ed zhodnotit rozsah sklerotick\u00fdch zm\u011bn a charakter aterosklerotick\u00e9ho pl\u00e1tu. Progrese sten\u00f3zy koreluje s rizikem klinick\u00e9ho projevu.Terapie asymptomatick\u00e9 sten\u00f3zy, kter\u00e1 je v\u00edce jak 50%, je st\u00e1le diskutov\u00e1na. Terapie statiny s terapi\u00ed antiagrega\u010dn\u00ed v\u00fdrazn\u011b m\u016f\u017ee v\u00fdrazn\u011b ovlivnit (zpomalit)pr\u016fb\u011bh onemocn\u011bn\u00ed.Z\u00e1va\u017enost symptomatick\u00e9 formy karotick\u00e9 sten\u00f3zy je spojena se stupn\u011bm sten\u00f3zy a sten\u00f3za je indikov\u00e1na k chirurgick\u00e9 nebo endovaskul\u00e1rn\u00ed l\u00e9\u010db\u011b.<\/p>\n<h6>DIAGNOSTIKA<\/h6>\n<p style=\"text-align: justify;\">U symptomatick\u00fdch forem je z\u00e1sadn\u00ed anamn\u00e9za, fyzik\u00e1ln\u00ed a neurologick\u00e9 vy\u0161et\u0159en\u00ed. Pr\u016fkaz asymptomatick\u00e9 formy je bu\u010f n\u00e1hodn\u00fd (p\u0159i angiologick\u00e9m screeningu) nebo c\u00edlen\u00fd n\u00e1lez (nap\u0159. v r\u00e1mci p\u0159edopera\u010dn\u00edho vy\u0161et\u0159en\u00ed).U obou forem je z\u00e1sadn\u00ed ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed. V p\u0159\u00edpad\u011b nejasn\u00e9 diagn\u00f3zy se dopl\u0148uje NMR ag nebo CT ag.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Barevn\u00e1 duplexn\u00ed sonografie pop\u00ed\u0161e rozsah sten\u00f3zy a stabilitu pl\u00e1tu. Metoda se pova\u017euje za natolik senzitivn\u00ed, \u017ee 95% center indikuje na z\u00e1klad\u011b UZ vy\u0161et\u0159en\u00ed l\u00e9\u010dbu (v\u010detn\u011b chirurgick\u00e9 CEA). Sonografie je nezbytn\u00e1 tak\u00e9 p\u0159i poopera\u010dn\u00ed monitoraci stavu.<\/li>\n<li style=\"text-align: justify;\">NMR ag: v\u00fdhodou metody je nejenom zobrazen\u00ed karotick\u00e9ho \u0159e\u010di\u0161t\u011b, ale zobrazen\u00ed v\u0161ech v\u011btv\u00ed oblouku aorty a zobrazen\u00ed intrakrani\u00e1ln\u00ed \u0159e\u010di\u0161t\u011b. Metoda zobraz\u00ed vaskul\u00e1rn\u00ed anom\u00e1lie, hemodynamick\u00e1 onemocn\u011bn\u00ed (subclavian stealsy) a jin\u00e9 zm\u011bny na \u0159e\u010di\u0161ti (kinking krkavice). Metoda m\u00e1 zn\u00e1m\u00e9 kontraindikace.<\/li>\n<li style=\"text-align: justify;\">CT ag m\u00e1 podobn\u00e9 indikace jako NMR ag a je v\u011bt\u0161inou dostupn\u011bj\u0161\u00ed. Zobraz\u00ed extra a intrakrani\u00e1ln\u00ed anatomick\u00e9 zm\u011bny a funk\u010dnost \u0159e\u010di\u0161t\u011b. Riziko p\u0159edstavuje radia\u010dn\u00ed z\u00e1t\u011b\u017e a pod\u00e1n\u00ed kontrastn\u00ed l\u00e1tky.<\/li>\n<li style=\"text-align: justify;\">Digit\u00e1ln\u00ed subtrak\u010dn\u00ed angiografie z\u016fst\u00e1v\u00e1 pro mnoho pracovi\u0161\u0165 d\u00edky sv\u00e9 p\u0159esnosti zlat\u00fdm standardem. Dokonale zobraz\u00ed oblouk aorty a jej\u00ed v\u011btve, extrakrani\u00e1ln\u00ed a intrakrani\u00e1ln\u00ed cirkulaci. Jej\u00edm rizikem je pod\u00e1n\u00ed kontrastn\u00ed l\u00e1tky a zku\u0161enost, \u017ee 1\u20132% nemocn\u00fdch m\u00e1 po vy\u0161et\u0159en\u00ed neurologick\u00fd deficit.<\/li>\n<\/ul>\n<h6>TERAPIE<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Asymptomatick\u00e9 sten\u00f3zy<\/strong><br \/>\nStudie (ACAS, ACST) prok\u00e1zaly, \u017ee nemocn\u00fdm s karotickou sten\u00f3zou 60\u201399% p\u0159in\u00e1\u0161\u00ed v\u011bt\u0161\u00ed benefit karotick\u00e1 endarterektomie (CEA) v kombinaci s medikament\u00f3zn\u00ed terapi\u00ed (kyselina acetylsalicylov\u00e1 a obecn\u011b l\u00e9ky, kter\u00e9 sni\u017euj\u00ed aterosklerotick\u00e9 rizikov\u00e9 faktory) ne\u017e samostatn\u00e1 medikament\u00f3zn\u00ed terapie.CEA mus\u00ed b\u00fdt prov\u00e1d\u011bna na pracovi\u0161ti, kde je po\u010det komplikac\u00ed (CMP a \u00famrt\u00ed) do 30 dn\u016f po operaci pod 3,9% se snahou dos\u00e1hnout 1,5% komplikac\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>Symptomatick\u00e9 sten\u00f3zy<\/strong><br \/>\nBenefit CEA je u symptomatick\u00fdch sten\u00f3z v\u00fdrazn\u011bj\u0161\u00ed ne\u017e u asymptomatick\u00fdch. Je tak\u00e9 z\u0159ejm\u00e9,\u017ee v\u00fdskyt periopera\u010dn\u00edch komplikac\u00ed je 4\u00d7 vy\u0161\u0161\u00ed.Progn\u00f3za nemocn\u00fdch se symptomatickou sten\u00f3zou l\u00e9\u010denou konzervativn\u011b je ve srovn\u00e1n\u00ed s nemocn\u00fdmi s asymptomatickou konzervativn\u011b l\u00e9\u010denou sten\u00f3zou v\u00fdrazn\u011b hor\u0161\u00ed. P\u0159\u00ednos CEA je z\u0159ejm\u00fd p\u0159edev\u0161\u00edm u sten\u00f3z 70\u201399%. Studie (NASCET a ACAS) srovn\u00e1vaj\u00ed nemocn\u00e9 se symptomatickou karotickou sten\u00f3zou, kte\u0159\u00ed jsou l\u00e9\u010deni konzervativn\u011b, versus CEA + konzervativn\u00ed terapie. B\u011bhem 2let\u00e9ho sledov\u00e1n\u00ed byl v\u00fdskyt ipsilater\u00e1ln\u00ed CMP v prvn\u00ed skupin\u011b 26% a v operovan\u00e9 9%. V\u00fdskyt komplikac\u00ed do 30 dn\u016f (CMP a \u00famrt\u00ed) je do 3%.<\/li>\n<li style=\"text-align: justify;\">\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_231.png\"><img decoding=\"async\" title=\"Obr. 6a Kinking vnit\u0159n\u00ed aorty\" alt=\"Obr. 6a Kinking vnit\u0159n\u00ed aorty\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_231.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6a<br \/>Kinking vnit\u0159n\u00ed aorty<\/p><\/div>\n<p><strong>Karotick\u00e1 endarterektomie (CEA)<\/strong><br \/>\nV souvislosti s indikac\u00ed k CEA je tak\u00e9 indikov\u00e1na periopera\u010dn\u00ed terapie. Jedn\u00e1 se o antiagrega\u010dn\u00ed terapii. Benefit z pod\u00e1v\u00e1n\u00ed kyseliny acetylsalicylov\u00e9 spo\u010d\u00edv\u00e1 ve sn\u00ed\u017een\u00ed poopera\u010dn\u00edch CMP. Podobn\u00e9 v\u00fdsledky m\u00e1 pod\u00e1n\u00ed clopidogrelu a nebo kombinace obou prepar\u00e1t\u016f. Jejich pod\u00e1n\u00ed ovliv\u0148uje chirurgick\u00fd v\u00fdkon v\u00fdrazn\u00fdm krv\u00e1cen\u00edm.<br \/>\nPeropera\u010dn\u011b p\u0159ed nalo\u017een\u00edm svorek na v\u011btve karotick\u00e9 vidlice se pod\u00e1v\u00e1 heparin. Kombinace aspirinu s heparinem se pova\u017euje za nejefektivn\u011bj\u0161\u00ed v prevenci tromb\u00f3zy. V pod\u00e1n\u00ed protaminsulf\u00e1tuna konci opera\u010dn\u00edho v\u00fdkonu nen\u00ed jednotn\u00fd n\u00e1zor.Jeho nepod\u00e1n\u00ed m\u016f\u017ee zv\u00fd\u0161it krv\u00e1cen\u00ed z uzav\u0159en\u00e9 arteriotomie, ale sou\u010dasn\u011b je sn\u00ed\u017eeno riziko tromb\u00f3zy na endarterektomovan\u00e9m \u00faseku krkavice. Jin\u00e9 studie neprok\u00e1zaly vliv protaminu na vznik poopera\u010dn\u00ed CMP (GALA).Pod\u00e1n\u00ed statin\u016f aspo\u0148 jeden m\u011bs\u00edc p\u0159ed CEA sni\u017euje v\u00fdskyt poopera\u010dn\u00edch CMP. Sou\u010dasn\u011b maj\u00ed pozitivn\u00ed vliv na vznik peropera\u010dn\u00edch kardi\u00e1ln\u00edch komplikac\u00ed.Karotick\u00e1 endarterektomie se prov\u00e1d\u00ed bu\u010f v celkov\u00e9 nebo region\u00e1ln\u00ed anestezii. Celkov\u00e1 anestezie p\u0159edstavuje pro nemocn\u00e9ho nebo i pro chirurga v\u011bt\u0161\u00ed komfort, je v\u0161ak nutn\u00e9 b\u011bhem operace pou\u017e\u00edt intralumin\u00e1ln\u00ed shunt. Region\u00e1ln\u00ed anestezie s hlubok\u00fdm cervik\u00e1ln\u00edm blokem umo\u017e\u0148uje komunikacis nemocn\u00fdm a aktu\u00e1ln\u00ed posouzen\u00ed mozkov\u00e9 perfuze po uzav\u0159en\u00ed karotick\u00e9 vidlice. P\u0159i zachov\u00e1n\u00ed v\u011bdom\u00ed nen\u00ed pou\u017eit\u00ed intralumin\u00e1ln\u00edho shuntu indikov\u00e1no. Preparace karotick\u00e9 vidlice vy\u017eaduje jen nejnutn\u011bj\u0161\u00ed manipulaci s arteriemi pro riziko intraopera\u010dn\u00ed embolizace. Karotick\u00e9 \u0159e\u010di\u0161t\u011b m\u016f\u017ee b\u00fdt v\u00fdrazn\u011b vinut\u00e9 (foto 6a). Vlastn\u00ed chirurgick\u00fd v\u00fdkon na karotick\u00e9 vidlici m\u016f\u017ee b\u00fdt konven\u010dn\u00ed nebo everzn\u00ed. Konven\u010dn\u00ed CEA spo\u010d\u00edv\u00e1 v pod\u00e9ln\u00e9 arteriotomii spole\u010dn\u00e9 a vnit\u0159n\u00ed karotidy s vyjmut\u00edm pl\u00e1tu tak, \u017ee se ve spole\u010dn\u00e9 karotid\u011b protne pl\u00e1t ost\u0159e (je po proudu) a ve vnit\u0159n\u00ed karotid\u011b se odstran\u00ed \u201edo ztracena\u201c (pl\u00e1t je proti proudu). Vrstva, ve kter\u00e9 se pl\u00e1t odd\u011bluje, by m\u011bla b\u00fdt mezi intimou a medi\u00ed, ale v\u011bt\u0161inou pro pokro\u010dil\u00e9 sklerotick\u00e9 zm\u011bny prob\u00edh\u00e1 v medii. Arteriotomie se uzav\u00edr\u00e1 dle kalibru vnit\u0159n\u00ed karotidy pokra\u010duj\u00edc\u00edm stehem (foto 6b) nebo pomoc\u00ed z\u00e1platy (\u017eiln\u00ed nebo ePTFE). Everzn\u00ed CEA spo\u010d\u00edv\u00e1 v prot\u011bt\u00ed vnit\u0159n\u00ed karotidy v karotick\u00e9 vidlici. Po zachycen\u00ed cirkul\u00e1rn\u00edho pl\u00e1tu ve vnit\u0159n\u00ed karotid\u011b se evertuje adventitie a pl\u00e1t se vyjme. Otvorem ve vidlici se stejnou technikou vyjme pl\u00e1t ze spole\u010dn\u00e9 a zevn\u00ed karotidy. Po CEA se vnit\u0159n\u00ed karotida anastom\u00f3zou endto-end na\u0161\u00edv\u00e1 do p\u016fvodn\u00ed lokalizace. Pokud nelze p\u0159i CEA odstranit aterosklerotick\u00fd pl\u00e1t \u201edo ztracena\u201c, je mo\u017en\u00e9 vidlici resekovat a nahradit ji \u017eiln\u00edm nebo ePTFE interpon\u00e1tem foto 6c. Po ukon\u010den\u00ed v\u00fdkonu na c\u00e9vn\u00edm svazku se vkl\u00e1d\u00e1 redon\u016fv dr\u00e9n a r\u00e1na se uzav\u00edr\u00e1 po anatomick\u00fdch vrstv\u00e1ch.<\/li>\n<\/ul>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 6b:<br \/>\nkarotick\u00e1 endarterektomie CEA<\/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_233.png\"><img decoding=\"async\" title=\"Preparace karotick\u00e9 vidlice\" alt=\"Preparace karotick\u00e9 vidlice\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_233.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Preparace karotick\u00e9 vidlice<\/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_236.png\"><img decoding=\"async\" title=\"Arteriotomie v luminu \u2013 sklerotick\u00fd pl\u00e1t\" alt=\"Arteriotomie v luminu \u2013 sklerotick\u00fd pl\u00e1t\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_236.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Arteriotomie v luminu \u2013 sklerotick\u00fd pl\u00e1t<\/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_234.png\"><img decoding=\"async\" title=\"Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu I. Sklerotick\u00fd\" alt=\"Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu I. Sklerotick\u00fd\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_234.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu I.<br \/>Sklerotick\u00fd<\/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_237.png\"><img decoding=\"async\" title=\"Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu II.\" alt=\"Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu II.\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_237.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Odstran\u011bn\u00ed sklerotick\u00e9ho pl\u00e1tu 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_235.png\"><img decoding=\"async\" title=\"Sklerotick\u00fd cylindrick\u00fd pl\u00e1t \u2013 odlitek vidlice\" alt=\"Sklerotick\u00fd cylindrick\u00fd pl\u00e1t \u2013 odlitek vidlice\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_235.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Sklerotick\u00fd cylindrick\u00fd pl\u00e1t \u2013 odlitek vidlice<\/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_238.png\"><img decoding=\"async\" title=\"Prim\u00e1rn\u00ed sutura arterie\" alt=\"Prim\u00e1rn\u00ed sutura arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_238.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Prim\u00e1rn\u00ed sutura arterie<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li><strong>Komplikace CEA<\/strong>\n<ul>\n<li style=\"text-align: justify;\">Kardi\u00e1ln\u00ed \u2013 infarkt myokardu je p\u0159\u00ed\u010dinou 25 a\u017e 50% periopera\u010dn\u00edch \u00famrt\u00ed po CEA. Z\u00e1sadn\u00ed je prevence a dokonal\u00e9 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed se zhodnocen\u00edm kardi\u00e1ln\u00edho n\u00e1lezu.<\/li>\n<li style=\"text-align: justify;\">Poran\u011bn\u00ed krani\u00e1ln\u00edch nerv\u016f \u2013 lokalizace karotick\u00e9 vidlice p\u0159edstavuje anatomicky slo\u017eitou oblast s bohat\u00fdm c\u00e9vn\u00edm a nervov\u00fdm z\u00e1soben\u00edm.Iatrogenn\u00edmu poran\u011bn\u00ed se \u010dasto i p\u0159i pe\u010dliv\u00e9 preparaci chirurg nevyhne. V\u011bt\u0161inou se jedn\u00e1 o zhmo\u017ed\u011bn\u00ed, \u00fatlak hematomem nebo prot\u011bt\u00ed nervu.\u00a0Nej\u010dast\u011bji\u00a0b\u00fdvaj\u00ed posti\u017eeny n. hypoglossus, n. vagus (projevem je \u201eporan\u011bn\u00ed\u201c n. laryngeus rec.), n. laryngeus sup. a ko\u017en\u00ed senzitivn\u00ed nervy.<\/li>\n<li style=\"text-align: justify;\">Krv\u00e1cen\u00ed \u2013 v\u011bt\u0161inou se jedn\u00e1 o nechirurgick\u00e9 krv\u00e1cen\u00ed p\u0159i antiagrega\u010dn\u00ed terapii. P\u0159i v\u00fdrazn\u011bj\u0161\u00edm krv\u00e1cen\u00ed z r\u00e1ny a z dr\u00e9nu je nutn\u00e1 revize r\u00e1ny a vylou\u010den\u00ed nebo o\u0161et\u0159en\u00ed krv\u00e1cen\u00ed z arteriotomie. Rekurentn\u00ed sten\u00f3za karotidy se prok\u00e1\u017ee p\u0159i pravideln\u00e9 monitoraci nemocn\u00e9ho ultrazvukov\u00fdm vy\u0161et\u0159en\u00edm.Jej\u00ed v\u00fdskyt je asi u 10% nemocn\u00fdch v prvn\u00edm roce,potom jej\u00ed v\u00fdskyt kles\u00e1. Jej\u00ed p\u0159\u00ed\u010dinou je v\u011bt\u0161inou intim\u00e1ln\u00ed hyperplazie. Jej\u00ed o\u0161et\u0159en\u00ed m\u016f\u017ee b\u00fdt op\u011bt chirurgick\u00e9, kdy operace v jizevnat\u00e9 tk\u00e1ni je technicky n\u00e1ro\u010dn\u00e1 s rizikem poran\u011bn\u00ed okoln\u00edch struktur, nebose resten\u00f3za o\u0161et\u0159\u00ed endovaskul\u00e1rn\u011b PTA a stentem.<\/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=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 6c:<br \/>\nresekce<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" rowspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 160px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_241.jpg\"><img decoding=\"async\" title=\"Obr. 3\" alt=\"Obr. 3\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_241.jpg\" width=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<div style=\"width: 210px\" class=\"wp-caption alignnone\"><a style=\"line-height: 19px;\" href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_240.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 1\" alt=\"Obr. 1\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_240.jpg\" width=\"200\" height=\"142\" \/><\/a><p class=\"wp-caption-text\">Obr. 1<\/p><\/div>\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a style=\"line-height: 19px;\" href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_242.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 2\" alt=\"Obr. 2\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_242.jpg\" width=\"200\" height=\"104\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Alternativn\u00ed metodou k prim\u00e1rn\u00ed CEA je endovaskul\u00e1rn\u00ed o\u0161et\u0159en\u00ed karotick\u00e9 sten\u00f3zy cestou PTA a stentu. P\u0159etrv\u00e1v\u00e1 diskuze o v\u00fdhod\u00e1ch a nev\u00fdhod\u00e1ch t\u00e9to metody, jednozna\u010dn\u00fd z\u00e1v\u011br zat\u00edm neexistuje, ale za z\u00e1sadn\u00ed se pova\u017euje, aby c\u00e9vn\u00ed centra byla schopna nab\u00eddnout ob\u011b metody a individu\u00e1ln\u011b volit l\u00e9\u010dbu dle celkov\u00e9ho stavu nemocn\u00e9ho. Endovaskul\u00e1rn\u00ed terapie karotick\u00fdch sten\u00f3z m\u00e1 vy\u0161\u0161\u00ed v\u00fdskyt komplikac\u00ed u symptomatick\u00fdch sten\u00f3z ne\u017e CEA.<\/p>\n<h6>KAROTICK\u00c9 \u0158E\u010cI\u0160T\u011a \u2013 FIBROMUSKUL\u00c1RN\u00cd DYSPLAZIE<\/h6>\n<p style=\"text-align: justify;\">Fibromuskul\u00e1rn\u00ed dysplazie (FMD) je neateromat\u00f3zn\u00ed degenerativn\u00ed proces, kter\u00fd postihuje dlouh\u00e9 \u00faseky art\u00e9ri\u00ed st\u0159edn\u00edho kalibru. Typick\u00e9 je posti\u017een\u00ed ren\u00e1ln\u00ed nebo vnit\u0159n\u00ed karotick\u00e9 arterie. Etiologie onemocn\u011bn\u00ed nen\u00ed zn\u00e1ma. Diskutuje se vliv ischemie c\u00e9vn\u00ed st\u011bny (onemocn\u011bn\u00ed vasa vasorum), vlivy hormon\u00e1ln\u00ed, genetick\u00e9 a imunologick\u00e9.Projevy FMD jsou z hlediska patologicko-anatomick\u00e9ho n\u00e1lezu okluzivn\u00ed a aneuryzmatick\u00e9. Vnit\u0159n\u00ed karotida b\u00fdv\u00e1 posti\u017eena ve st\u0159edn\u00edm a dist\u00e1ln\u00edm \u00faseku (aterosklerotick\u00e9 zm\u011bny jsou naopak ve vidlici a v proxim\u00e1ln\u00edm \u00faseku). P\u0159i posti\u017een\u00ed vnit\u0159n\u00ed karotidy je asi 10% FMD spojeno s klinick\u00fdmi projevy vypl\u00fdvaj\u00edc\u00edmi ze z\u00fa\u017een\u00ed lumen. To vede ke sn\u00ed\u017een\u00ed perfuze, vytv\u00e1\u0159\u00ed podm\u00ednky ke vzniku tromb\u016f a dist\u00e1ln\u00edch embolizac\u00ed. FMD m\u016f\u017ee b\u00fdt komplikov\u00e1na spont\u00e1nn\u00ed disekc\u00ed. Ta vede k CMP s velmi \u0161patnou progn\u00f3zou.Pokud m\u00e1 FMD neurologickou symptomatologii, prob\u00edh\u00e1 dal\u0161\u00ed vy\u0161et\u0159en\u00ed ve zvykl\u00e9m algoritmu \u2013 UZ, NMR ag a CT ag. U asymptomatick\u00fdch nemocn\u00fdch je indikac\u00ed k vy\u0161et\u0159en\u00ed \u0161elest nad karotidou nebo se jedn\u00e1 o n\u00e1hodn\u00fd n\u00e1lez p\u0159i angiologick\u00e9m screeningu.Terapie asymptomatick\u00e9 FMD je konzervativn\u00ed antiagrega\u010dn\u00ed terapi\u00ed. P\u0159i progresi UZ n\u00e1lezu nebo p\u0159i vzniku neurologick\u00e9 symptomatologie je indikov\u00e1na chirurgick\u00e1 terapie, p\u0159i kter\u00e9 se prov\u00e1d\u00ed mechanick\u00e1 dilatace arterie po jej\u00ed arteriotomii ve v\u00fd\u0161i karotick\u00e9 vidlice. Jinou mo\u017enost\u00ed je endovaskul\u00e1rn\u00ed terapie \u2013 PTA.<\/p>\n<h6>KAROTICK\u00c9 \u0158E\u010cI\u0160T\u011a \u2013 ANEURYZMA<\/h6>\n<p style=\"text-align: justify;\">Aneuryzma extrakrani\u00e1ln\u00edho karotick\u00e9ho \u0159e\u010di\u0161t\u011b vznik\u00e1 nej\u010dast\u011bji na aterosklerotick\u00e9m podkladu. Jin\u00fdmi p\u0159\u00ed\u010dinami jsou trauma arterie, jej\u00ed disekce, infekce nebo komplikace po CEA. Jejich v\u00fdskyt je vz\u00e1cn\u00fd.<\/p>\n<p style=\"text-align: justify;\">Klinick\u00e9 projevy jsou pulzuj\u00edc\u00ed rezistence krku, neurologick\u00e1 symptomatologie vypl\u00fdvaj\u00edc\u00ed z embolizace materi\u00e1lu v\u00fddut\u011b do CNS, dysfunkce hlavov\u00fdch nerv\u016f, dysf\u00e1gie, krv\u00e1cen\u00ed z v\u00fddut\u011b a jej\u00ed ruptura.Z vy\u0161et\u0159ovac\u00edch metod je vhodn\u00e1 barevn\u00e1 duplexn\u00ed sonografie, NMR ag a CT ag.<\/p>\n<p style=\"text-align: justify;\">Terapie: z historie je nejb\u011b\u017en\u011bj\u0161\u00ed ligace, kter\u00e1 m\u016f\u017ee zp\u016fsobit v\u00fdraznou neurologickou symptomatologii. Nepova\u017euje se dnes za z\u00e1kladn\u00ed metodu o\u0161et\u0159en\u00ed, ale je nezbytn\u00e1 p\u0159i ruptu\u0159e v\u00fddut\u011b, p\u0159edev\u0161\u00edm u infikovan\u00fdch v\u00fddut\u00ed. Resekce v\u00fddut\u011b s interpozic\u00ed je indikov\u00e1na u nemocn\u00fdch, kde v\u00fddu\u0165 postihuje spole\u010dnou karotidu a proxim\u00e1ln\u00ed t\u0159etinu a. carotis interna. P\u0159i posti\u017een\u00ed vy\u0161\u0161\u00edch et\u00e1\u017e\u00ed karotick\u00e9ho \u0159e\u010di\u0161t\u011b je indikov\u00e1na endovaskul\u00e1rn\u00ed l\u00e9\u010dba \u2013 zav\u00e1d\u011bj\u00ed se stenty se sou\u010dasn\u00fdm coilingem v\u00fddut\u011b (transstent coiling embolization) nebo se zav\u00e1d\u00ed stentgraft.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>KAROTICK\u00c9 \u0158E\u010cI\u0160T\u011a \u2013 OBLITERUJ\u00cdC\u00cd ATEROSKLER\u00d3ZA Z\u00e1kladn\u00edm \u00fakolem l\u00e9\u010dby cerebrovaskul\u00e1rn\u00edch onemocn\u011bn\u00ed je zabr\u00e1nit c\u00e9vn\u00ed mozkov\u00e9 p\u0159\u00edhod\u011b (CMP). Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou je aterosklerotick\u00fd proces. Postaven\u00ed chirurga se v t\u00e9to problematice m\u011bn\u00ed a je z\u00e1visl\u00e9 na sou\u010dasn\u00fdch poznatc\u00edch patofyziologie procesu CMP, na dostupnosti zobrazovac\u00edch technik a na rozvoji chirurgick\u00fdch a endovaskul\u00e1rn\u00edch metod. Volba nejspr\u00e1vn\u011bj\u0161\u00ed metody podl\u00e9h\u00e1 v\u00fdsledk\u016fm cel\u00e9 \u0159ady [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":30,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2202","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2202","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=2202"}],"version-history":[{"count":17,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2202\/revisions"}],"predecessor-version":[{"id":2221,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2202\/revisions\/2221"}],"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=2202"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}