{"id":2282,"date":"2013-04-08T08:47:10","date_gmt":"2013-04-08T08:47:10","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2282"},"modified":"2013-06-11T12:25:25","modified_gmt":"2013-06-11T12:25:25","slug":"9-ruzne","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2282","title":{"rendered":"9 R\u016fzn\u00e9"},"content":{"rendered":"<h6>MEDIKAMENT\u00d3ZN\u00cd TERAPIE\u00a0PO C\u00c9VN\u011aCHIRURGICK\u00ddCH V\u00ddKONECH\u00a0A PO ENDOVASKUL\u00c1RN\u00cdCH INTERVENC\u00cdCH<\/h6>\n<p style=\"text-align: justify;\">Nemocn\u00ed, kte\u0159\u00ed podstoupili v\u00fdkon na c\u00e9vn\u00edm \u0159e\u010di\u0161ti, vy\u017eaduj\u00ed n\u00e1slednou optimalizovanou l\u00e9\u010dbu, kter\u00e1 by m\u011bla modifikovat nebo eliminovat kardiovaskul\u00e1rn\u00ed rizikov\u00e9 faktory, a t\u00edm preventivn\u011b ovlivnit progresi z\u00e1kladn\u00edho v\u011bt\u0161inou aterosklerotick\u00e9ho onemocn\u011bn\u00ed. Doporu\u010den\u00e1 l\u00e9\u010dba vych\u00e1z\u00ed z definic\u00ed American Heart Association a Evropsk\u00e9 spole\u010dnost\u00ed pro kardiologii. Je p\u0159ihl\u00e9dnuto k poznatk\u016fm vypl\u00fdvaj\u00edc\u00edm ze systematick\u00fdch liter\u00e1rn\u00edch re\u0161er\u0161\u00ed.<\/p>\n<h6>KARDIOVASKUL\u00c1RN\u00cd RIZIKOV\u00c9 FAKTORY A JEJICH KONTROLA<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010dba hyperlipidemie<br \/>\n<\/strong>Je indikov\u00e1na terapie statiny. Hladina LDL-cholesterolu by m\u011bla b\u00fdt pod 2,58 mmol\/l. U nemocn\u00fdch s vysok\u00fdm kardiovaskul\u00e1rn\u00edm rizikem je snaha dos\u00e1hnout hladiny pod 1,81 mmol\/l. U nemocn\u00fdch s n\u00edzkou hladinou HDL cholesterolu, norm\u00e1ln\u00edm LDL-cholesterolem a se zv\u00fd\u0161enou hladinou triglycerid\u016f je indikov\u00e1na sou\u010dasn\u00e1 terapie fibr\u00e1ty.<\/li>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010dba hypertenze<\/strong><br \/>\nPomoc\u00ed antihypertensiv je t\u0159eba zajistit normotenzi 140\/90 mm Hg u b\u011b\u017en\u00fdch nemocn\u00fdch. U diabetik\u016f a u nemocn\u00fdch s chronickou ledvinnou nedostate\u010dnost\u00ed je t\u0159eba upravit TK pod 130\/80 mm Hg. Tatokorekce sni\u017euje riziko infarktu myokardu, c\u00e9vn\u00edch mozkov\u00fdch p\u0159\u00edhod a srde\u010dn\u00edho selh\u00e1n\u00ed. Betablok\u00e1tory nejsou kontraindikov\u00e1ny u nemocn\u00fdch s uz\u00e1v\u011bry perifern\u00edho arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b. ACE blok\u00e1tory lze pou\u017e\u00edt u nemocn\u00fdch se symptomatickou i asymptomatickou formou onemocn\u011bn\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010dba diabetes mellitus<\/strong><br \/>\nC\u00edlem antidiabetick\u00e9 \u00a0l\u00e9\u010dby je dos\u00e1hnout hladinyHbA1C pod 7%.<\/li>\n<li style=\"text-align: justify;\"><strong>Nikotinismus<\/strong><br \/>\nNemocn\u00ed by se m\u011bli vzd\u00e1t kou\u0159en\u00ed. Je t\u0159eba vyu\u017e\u00edt mo\u017enost\u00ed odvykac\u00edch k\u016fr a medikament\u00f3zn\u00edch n\u00e1hrad nikotinu.<\/li>\n<li style=\"text-align: justify;\"><strong>Ovlivn\u011bn\u00ed hladiny homocysteinu<\/strong><br \/>\nEfektivita redukce hladiny homocysteinu pomoc\u00ed kyseliny listov\u00e9 a vitaminu B12 nebyla u nemocn\u00fdch s ateroskler\u00f3zou prok\u00e1z\u00e1na.<\/li>\n<li style=\"text-align: justify;\"><strong>Antiagrega\u010dn\u00ed a peror\u00e1ln\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dba<br \/>\n<\/strong>Efektivita antiagrega\u010dn\u00ed terapie je prok\u00e1z\u00e1na u sekund\u00e1rn\u00edch vaskul\u00e1rn\u00edch komplikac\u00ed, jako jsou srde\u010dn\u00ed infarkt, c\u00e9vn\u00ed mozkov\u00e1 p\u0159\u00edhoda nebo \u00famrt\u00ed z c\u00e9vn\u00edch p\u0159\u00ed\u010din. Za vhodn\u00e1 antiagreganci a se pova\u017euj\u00ed kyselina acetylsalicylov\u00e1 v d\u00e1vce 75\u2013325 mg\/den (v\u011bt\u0161inou 100 mg\/den) nebo alternativn\u011b clopidogrel v d\u00e1vce 75 mg\/den. Pou\u017eit\u00ed peror\u00e1ln\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dby (antagonist\u00e9 vitam\u00ednu K) se k profylaxi obecn\u011b nedoporu\u010duje.<\/li>\n<li style=\"text-align: justify;\"><strong>Obecn\u00e1 periopera\u010dn\u00ed medikace (antiagregace,\u00a0betablok\u00e1tory, statiny)<\/strong><br \/>\nL\u00e9\u010dba kyselinou acetylsalicylovou se nemus\u00ed periopera\u010dn\u011b p\u0159eru\u0161it. Doporu\u010duje se vysadit l\u00e9\u010dbu clopidogrelem nejm\u00e9n\u011b 1 t\u00fdden p\u0159ed v\u00fdkonem pro zv\u00fd\u0161enou krv\u00e1civost. Je mo\u017enost p\u0159eveden\u00ed nemocn\u00fdch na kyselinu acetylosalicylovou. U nemocn\u00fdch s pl\u00e1novan\u00fdm chirurgick\u00fdm v\u00fdkonem na arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti pro aterosklerotick\u00e9 onemocn\u011bn\u00ed se doporu\u010duje nejm\u00e9n\u011b 1 t\u00fdden p\u0159ed v\u00fdkonem nasadit betablok\u00e1tory (tzv. peropera\u010dn\u011b), kter\u00e9 minimalizuj\u00ed riziko peropera\u010dn\u00ed kardi\u00e1ln\u00ed ischemie. To neplat\u00ed pro nemocn\u00e9 s absolutn\u00ed kontraindikac\u00ed k l\u00e9\u010db\u011b betablok\u00e1tory. U nemocn\u00fdch s pl\u00e1novan\u00fdm chirurgick\u00fdm v\u00fdkonem na arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti pro aterosklerotick\u00e9 onemocn\u011bn\u00ed se doporu\u010duje nejm\u00e9n\u011b 1 m\u011bs\u00edc p\u0159ed v\u00fdkonem (tzv. peropera\u010dn\u011b) nasadit statiny. Jejich pod\u00e1n\u00ed nesouvis\u00ed s hladinou cholesterolu v s\u00e9ru.Tato terapie minimalizuje riziko peropera\u010dn\u00ed kardi\u00e1ln\u00ed komplikace.<\/li>\n<\/ul>\n<h6>ANTIAGREGA\u010cN\u00cd, ANTIKOAGULA\u010cN\u00cd L\u00c9\u010cBA PO C\u00c9VN\u011a CHIRURGICK\u00ddCH V\u00ddKONECH\u00a0A PO ENDOVASKUL\u00c1RN\u00cdCH INTERVENC\u00cdCH.<\/h6>\n<ul>\n<li style=\"text-align: justify;\">V\u011btve oblouku aorty (krkavice, subklavie, truncus brachiocephalicus, vertebr\u00e1ln\u00ed a brachi\u00e1ln\u00ed arterie)\n<ul>\n<li>A. carotis \u2013 endovaskul\u00e1rn\u00ed l\u00e9\u010dba: po o\u0161et\u0159en\u00ed karotick\u00e9 sten\u00f3zy cestou PTA a stentu se doporu\u010duje l\u00e9\u010dba kyselinou acetylsalicylovou a clopidogrelem. Terapie clopidogrelem za\u010d\u00edn\u00e1 p\u0159ed v\u00fdkonem, nejpozd\u011bji den p\u0159ed v\u00fdkonem tzv. loading dose 300 mg (potom 75 mg\/den) a n\u00e1sledn\u011b se po 4\u201312 t\u00fddnech vysazuje. Terapie kyselinou acetylsalicylovou je celo\u017eivotn\u00ed.<\/li>\n<li>A. carotis \u2013 chirurgick\u00e1 l\u00e9\u010dba: po karotick\u00e9 endarterektomii je indikov\u00e1na celo\u017eivotn\u00ed antiagrega\u010dn\u00ed l\u00e9\u010dba. Nen\u00ed v\u0161ak z\u0159ejm\u00e1 optim\u00e1ln\u00ed d\u00e1vka kyseliny acetylsalicylov\u00e9 (resp. \u017e\u00e1dn\u00e1 studie ji nedefinovala).<\/li>\n<li>A. subclavia, truncus brachiocephalicus, a. vertebralis, a. brachialis \u2013 endovaskul\u00e1rn\u00ed l\u00e9\u010dba: specifick\u00e9 doporu\u010den\u00ed terapie b\u011bhem endovaskul\u00e1rn\u00edho v\u00fdkonu a po v\u00fdkonu nelze vyslovit, proto\u017ee nejsou k dispozici dostate\u010dn\u00e1 data. Obecn\u011b lze doporu\u010dit trvalou l\u00e9\u010dbu kyselinou acetylsalicylovou s eventu\u00e1ln\u00edm kr\u00e1tkodob\u00fdm dopln\u011bn\u00edm clopidogrelem.<\/li>\n<li>A. subclavia, truncus brachiocephalicus, a. vertebralis, a. brachialis \u2013 chirurgick\u00e1 l\u00e9\u010dba: tak\u00e9 pro chirurgickou l\u00e9\u010dbu nejsou dostate\u010dn\u00e9 podklady. Lze pou\u017e\u00edt zku\u0161enost\u00ed z chirurgie doln\u00edch kon\u010detin a doporu\u010dit po trombendarterektomii a po aloplastick\u00e9m bypassu antiagrega\u010dn\u00ed l\u00e9\u010dbu. Po zalo\u017een\u00ed \u017eiln\u00edho bypassu lze doporu\u010dit peror\u00e1ln\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dbu.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Aorta (hrudn\u00ed a b\u0159i\u0161n\u00ed), v\u010detn\u011b viscer\u00e1ln\u00edch a p\u00e1nevn\u00edch v\u011btv\u00ed \u2013 endovaskul\u00e1rn\u00ed l\u00e9\u010dba: doporu\u010duje se trval\u00e1 antiagrega\u010dn\u00ed terapie, ev. v\u00fdhody antikoagula\u010dn\u00ed l\u00e9\u010dby nebyly prok\u00e1z\u00e1ny.<\/li>\n<li style=\"text-align: justify;\">Aorta (hrudn\u00ed a b\u0159i\u0161n\u00ed), v\u010detn\u011b viscer\u00e1ln\u00edch a p\u00e1nevn\u00edch v\u011btv\u00ed \u2013 chirurgick\u00e1 l\u00e9\u010dba: doporu\u010duje se trval\u00e1 antiagrega\u010dn\u00ed terapie, ev. v\u00fdhody antikoagula\u010dn\u00ed l\u00e9\u010dby nebyly prok\u00e1z\u00e1ny.<\/li>\n<li style=\"text-align: justify;\">Infrainguin\u00e1ln\u00ed v\u00fdkony \u2013 endovaskul\u00e1rn\u00ed: infrainguin\u00e1ln\u00ed PTA se nebo bez stentu vy\u017eaduje celo\u017eivotn\u00ed terapii kyselinou acetylsalicylovou (75\u2013325 mg\/den). P\u0159i aplikaci stentu je vhodn\u00e1 4\u201312t\u00fddenn\u00ed terapie clopidogrelem. P\u0159edm\u011btem v\u00fdzkumu je ot\u00e1zka, zda dlouhodob\u00e9 pod\u00e1v\u00e1n\u00ed clopidogrelu m\u00e1 v\u00fdznam v prevenci resten\u00f3z.<\/li>\n<li style=\"text-align: justify;\">Infrainguin\u00e1ln\u00ed v\u00fdkony \u2013 chirurgick\u00e9: po trombendarterectomii v infrainguin\u00e1ln\u00ed oblasti je indikov\u00e1na trval\u00e1 l\u00e9\u010dba kyselinou acetylsalicylovou. \u017diln\u00ed infrainguin\u00e1ln\u00ed bypass je spojen s pod\u00e1v\u00e1n\u00edm\u00a0peror\u00e1ln\u00ed antikoagula\u010dn\u00ed terapie (pokud nen\u00ed z jin\u00e9ho d\u016fvodu z\u00e1sadn\u00ed kontraindikace). Studiemi je prok\u00e1z\u00e1no, \u017ee antikoagula\u010dn\u00ed terapie m\u00e1 lep\u0161\u00ed v\u00fdsledky z hlediska uz\u00e1v\u011bru bypassu ne\u017e terapie antiagrega\u010dn\u00ed. Tak\u00e9 ostatn\u00ed vaskul\u00e1rn\u00ed komplikace se vyskytuj\u00ed v men\u0161\u00edm rozsahu. C\u00edlov\u00e1 hladina INR je 3,0\u20134,5. L\u00e9\u010dba se pova\u017euje za v\u00fdhodnou i p\u0159i z\u0159ejm\u00e9m vysok\u00e9m riziku krv\u00e1cen\u00ed. Nen\u00ed jasn\u00fd ev. p\u0159\u00ednos kombinovan\u00e9 l\u00e9\u010dby antiagrega\u010dn\u00ed a antikoagula\u010dn\u00ed z hlediska pr\u016fchodnosti bypassu a progrese z\u00e1kladn\u00edho onemocn\u011bn\u00ed. U alloplastick\u00fdch bypass\u016f je indikov\u00e1na terapie antiagrega\u010dn\u00ed. U bypass\u016f pomoc\u00ed um\u011bl\u00fdch c\u00e9vn\u00edch n\u00e1hrad, kter\u00e9 maj\u00ed lumen men\u0161\u00ed ne\u017e 6 mm, m\u00e1 kombinovan\u00e1 terapie peror\u00e1ln\u00edmi antikoagulanciemi s antiagreganciemi pozitivn\u00ed vliv na pr\u016fchodnost bypassu. Je v\u0161ak vysok\u00e9 riziko krv\u00e1cen\u00ed a zvy\u0161uje se mortalita. Indikace k t\u00e9to kombinovan\u00e9 terapii se \u0159e\u0161\u00ed individu\u00e1ln\u011b \u2013 je t\u0159eba srovnat riziko uz\u00e1v\u011bru bypassu a riziko krv\u00e1cen\u00ed.<\/li>\n<\/ul>\n<h5>C\u00c9VN\u00cd N\u00c1HRADY<\/h5>\n<h6>AUTOLOGN\u00cd \u017d\u00cdLA<\/h6>\n<p style=\"text-align: justify;\">Jej\u00ed pou\u017eit\u00ed je metodou volby p\u0159i rekonstrukc\u00edch v infrainguin\u00e1ln\u00ed oblasti. \u00daseky \u017e\u00edly se po jejich rozst\u0159i\u017een\u00ed pou\u017e\u00edvaj\u00ed k uz\u00e1v\u011bru arteriotomi\u00ed (z\u00e1plata \u2013 patch). K n\u00e1hrad\u011b se pou\u017e\u00edv\u00e1 v. saphena magna, v. saphena parva a v. cephalica. V rekonstruk\u010dn\u00ed c\u00e9vn\u00ed chirurgii infikovan\u00fdch c\u00e9vn\u00edch prot\u00e9z se pou\u017e\u00edv\u00e1 femor\u00e1ln\u00ed \u017e\u00edla (v. femoralis superficialis).Pou\u017eit\u00e1 \u017e\u00edla mus\u00ed m\u00edt adekv\u00e1tn\u00ed kvalitu a kalibr. K vylou\u010den\u00ed postflebitick\u00fdch zm\u011bn a varix\u016f se p\u0159edopera\u010dn\u011b vy\u0161et\u0159uje \u017eiln\u00ed \u0159e\u010di\u0161t\u011b pomoc\u00ed barevn\u00e9 duplexn\u00ed sonografie.P\u0159i odb\u011bru \u017e\u00edly se klade d\u016fraz na notouch techniku, kter\u00e1 m\u00e1 zabr\u00e1nit poran\u011bn\u00ed \u017eiln\u00edho endotelu, a t\u00edm vyvolat kask\u00e1du repara\u010dn\u00edch proces\u016f (trombocyty, r\u016fstov\u00e9 faktory, medi\u00e1tory z\u00e1n\u011btu, proliferace hladk\u00fdch bun\u011bk a matrixu), kter\u00e9 vedou ke sten\u00f3z\u00e1m. Odebran\u00e1 \u017e\u00edla se proplachuje a dilatuje. K proplachu se v\u011bt\u0161inou pou\u017e\u00edv\u00e1 fyziologick\u00fd roztok nebo ringerlakt\u00e1t. \u0160etrn\u00e1 dilatace \u017e\u00edly je z\u00e1sadn\u00ed \u2013 prok\u00e1\u017ee ev. defekt ve st\u011bn\u011b (\u00fanik), sten\u00f3zy zp\u016fsoben\u00e9 adventi\u00e1ln\u00edmi pruhy a umo\u017en\u00ed zhodnocen\u00ed potenci\u00e1ln\u00edho kalibru \u017e\u00edly. Ne\u0161etrn\u00e1 dilatace m\u016f\u017ee zp\u016fsobit po\u0161kozen\u00ed endotelu \u017e\u00edly nebo i rupturu medie. D\u016fsledkem je zhor\u0161en\u00ed biomechanick\u00fdch vlastnost\u00ed graftu. Za optim\u00e1ln\u00ed tlak pova\u017eujeme 100 mm Hg. Kvalitu odb\u011bru lze pozitivn\u011b ovlivnit farmakologicky. Do proplachov\u00fdch roztok\u016f se p\u0159id\u00e1v\u00e1 heparin (sn\u00ed\u017een\u00ed tvorby mikrotromb\u016f a fibrinov\u00fdch depozit) a papaverin (prevence vasospasm\u016f).<\/p>\n<p style=\"text-align: justify;\">Odb\u011br \u017eiln\u00edho \u0161t\u011bpu m\u016f\u017ee b\u00fdt komplikov\u00e1n infekc\u00ed a\/nebo dehiscenc\u00ed r\u00e1ny. Dle zvyku pracovi\u0161t\u011b se ko\u017en\u00ed \u0159ez m\u016f\u017ee v\u00e9st v cel\u00e9 d\u00e9lce odeb\u00edran\u00e9 \u017e\u00edly (nejrizikov\u011bj\u0161\u00ed z hlediska komplikac\u00ed) nebo lze prov\u00e9st n\u011bkolik krat\u0161\u00edch \u0159ez\u016f s ponech\u00e1n\u00edm ko\u017en\u00edch m\u016fstk\u016f. \u017d\u00edlu lze tak\u00e9 odeb\u00edrat za endoskopick\u00e9 vizualizace. Tato metoda je sp\u00ed\u0161e ur\u010dena pro odb\u011bry pro kardiochirurgii, v c\u00e9vn\u00ed chirurgii, kdy jsou prov\u00e1d\u011bny odb\u011bry dlouh\u00fdch \u017eiln\u00edch \u00fasek\u016f, se p\u0159\u00edli\u0161 neprosadila.P\u0159i pl\u00e1nov\u00e1n\u00ed infrainguin\u00e1ln\u00edho rekonstruk\u010dn\u00edho v\u00fdkonu se v\u011bt\u0161inou pl\u00e1nuje pou\u017eit\u00ed ipsilater\u00e1ln\u00edho \u017eiln\u00edho interpon\u00e1tu (v. saphena magna). Autologn\u00ed ven\u00f3zn\u00ed interpon\u00e1t m\u016f\u017ee b\u00fdt ulo\u017een reverzn\u011b, nonreverzn\u011b a in situ.<\/p>\n<p style=\"text-align: justify;\">Reverzn\u00ed \u017eiln\u00ed graft znamen\u00e1, \u017ee \u017e\u00edla byla v celku vyjmuta, o\u0161et\u0159ena a oto\u010dena (reverzn\u011b konfigurov\u00e1na). Arteri\u00e1ln\u00ed krevn\u00ed proud je potom ve sm\u011bru chlopn\u00ed, kter\u00e9 nebyly o\u0161et\u0159eny. Nev\u00fdhodou m\u016f\u017ee b\u00fdt po oto\u010den\u00ed kalibr \u017e\u00edly, kdy jej\u00ed p\u016fvodn\u011b dist\u00e1ln\u00ed \u00fasek, kter\u00fd je u\u017e\u0161\u00ed, je p\u0159i rekonstrukci na\u0161it proxim\u00e1ln\u011b na arterii. Na dist\u00e1ln\u00ed anastom\u00f3ze jsou pom\u011bry opa\u010dn\u00e9 \u2013 \u017e\u00edla je \u0161irok\u00e1 a arterie \u00fazk\u00e1, tato disproporce je v\u00edce z\u0159ejm\u00e1 u krur\u00e1ln\u00edch bypass\u016f. \u017d\u00edla je ulo\u017eena p\u0159i bypassu ulo\u017eena anatomicky nebo extraanatomicky. Chlopn\u011b mohou b\u00fdt komplikac\u00ed p\u0159i trombektomii p\u0159i uz\u00e1v\u011bru bypassu.<\/p>\n<p style=\"text-align: justify;\">Nonreverzn\u00ed \u017eiln\u00ed graft m\u00e1 valvulotomem po\u0161kozeny chlopn\u011b \u2013 t\u00edm m\u00e1 b\u00fdt zlep\u0161en tok zvl\u00e1\u0161t\u011b u graftu mal\u00e9ho kalibru. Sou\u010dasn\u011b je zachov\u00e1n kalibr \u017e\u00edly ve vztahu k art\u00e9rii. Nonreverzn\u00ed graft je spojen s bohatou manipulac\u00ed s \u017eilou a t\u00edm je zv\u00fd\u0161eno riziko jej\u00edho poran\u011bn\u00ed \u2013 tuto nev\u00fdhodu vyrovn\u00e1v\u00e1 jeho o 20% lep\u0161\u00ed pr\u016ftok ne\u017e u reverzn\u00edho graftu.In situ \u017eiln\u00ed graft \u2013 k bypassu pou\u017eit\u00e1 velk\u00e1 safena je ponech\u00e1na in situ. Je mobilizov\u00e1n jej\u00ed proxim\u00e1ln\u00ed a dist\u00e1ln\u00ed \u00fasek k anastom\u00f3z\u00e1m, valvulotomem jsou poru\u0161eny chlopn\u011b k zaji\u0161t\u011bn\u00ed z hlediska \u017e\u00edly k opa\u010dn\u00e9mu sm\u011bru toku krve a jsou p\u0159eru\u0161eny v\u011btve safeny, aby se zabr\u00e1nilo vzniku arterioven\u00f3zn\u00edch p\u00ed\u0161t\u011bl\u00ed. Proxim\u00e1ln\u00ed anastom\u00f3za je um\u00edst\u011bna nej\u010dast\u011bji na spole\u010dnou femor\u00e1ln\u00ed arterii, dist\u00e1ln\u00ed anastom\u00f3za na poplite\u00e1ln\u00ed arterii (nad nebo pod kolenem), na b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b nebo na ped\u00e1ln\u00ed art\u00e9rii. Po na\u0161it\u00ed proxim\u00e1ln\u00ed arteri\u00e1ln\u00ed anastom\u00f3zy se napln\u00ed \u017eiln\u00ed bypass, funk\u010dn\u00ed chlope\u0148 br\u00e1n\u00ed toku a je poru\u0161ena valvulotomem, kter\u00fd se do \u017e\u00edly zavede n\u011bkterou z postrann\u00edch v\u011btv\u00ed safeny. K vyhled\u00e1n\u00ed a o\u0161et\u0159en\u00ed postrann\u00edch v\u011btv\u00ed safeny existuje n\u011bkolik technik \u2013 od invazivn\u00edho obna\u017een\u00ed safeny v cel\u00e9 d\u00e9lce (\u010dasto s komplikovan\u00fdm hojen\u00edm ko\u017en\u00edho \u0159ezu) po semiinvazivn\u00ed identifikaci postrann\u00edch v\u011btv\u00ed ultrazvukem nebo angioskopicky.\u017d\u00edly pa\u017ee: ipsilater\u00e1ln\u00ed velk\u00e1 safena je nevhodn\u011bj\u0161\u00ed \u017eiln\u00ed n\u00e1hrada, ale je prok\u00e1z\u00e1no, \u017ee a\u017e u 45% nemocn\u00fdch chyb\u00ed nebo nen\u00ed adekv\u00e1tn\u00ed kvality. Lze pou\u017e\u00edt\u00a0\u017e\u00edly pa\u017ee a p\u0159edlokt\u00ed, nejvhodn\u011bj\u0161\u00ed je cefalick\u00e1 \u017e\u00edla pa\u017ee, n\u00e1sleduje bazilick\u00e1 \u017e\u00edla. Podko\u017en\u00ed \u017e\u00edly p\u0159edlokt\u00ed jsou nejm\u00e9n\u011b pou\u017e\u00edvan\u00e9.Funkci (selh\u00e1n\u00ed) ven\u00f3zn\u00edho graftu ovliv\u0148uje \u0159ada faktor\u016f. Obecn\u011b se uv\u00e1d\u00ed, \u017ee uz\u00e1v\u011br graftu do 30 dn\u016f od implantace je zp\u016fsoben technickou chybou p\u0159i operaci. P\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt nedostate\u010dn\u00fd p\u0159\u00edtok (inflow), nap\u0159. p\u0159i nepoznan\u00e9 p\u0159ek\u00e1\u017ece na proxim\u00e1ln\u00ed art\u00e9rii, nebo tlakov\u00fd pokles p\u0159i kardiovaskul\u00e1rn\u00edm selh\u00e1v\u00e1n\u00ed. Jinou p\u0159\u00ed\u010dinou je nedostate\u010dn\u00fd v\u00fdtokov\u00fd trakt (outflow) p\u0159i pokro\u010dil\u00fdch sklerotick\u00fdch zm\u011bn\u00e1ch na b\u00e9rcov\u00e9m \u0159e\u010di\u0161ti. Tzv. zevn\u00ed faktory \u010dasn\u00e9ho selh\u00e1n\u00ed jsou rotace bypassu p\u0159i zav\u00e1d\u011bn\u00ed do tunelu nebo zevn\u00ed \u00fatlak hematomem. Do t\u00e9to skupiny selh\u00e1n\u00ed \u0159ad\u00edme tak\u00e9 syst\u00e9mov\u00e9 p\u0159\u00ed\u010diny, jako jsou hyperkoagula\u010dn\u00ed stavy. Tzv. vnit\u0159n\u00ed faktory selh\u00e1n\u00ed jsou nedostate\u010dn\u011b o\u0161et\u0159en\u00e9 chlopn\u011b nebo technicky nekvalitn\u00ed arteri\u00e1ln\u00ed anastom\u00f3za. Pozdn\u00ed selh\u00e1n\u00ed graftu je zp\u016fsobeno intim\u00e1ln\u00ed hyperplazi\u00ed, kter\u00e1 je indukov\u00e1na po\u0161kozen\u00edm \u017e\u00edly p\u0159i chirurgick\u00e9 manipulaci v kombinaci se st\u0159i\u017en\u00fdmi a ta\u017en\u00fdmi silami, kter\u00e9 jsou vyvol\u00e1ny krevn\u00edm tokem. Doch\u00e1z\u00ed k progresivn\u00edmu zes\u00edlen\u00ed intimy, z\u00fa\u017een\u00ed lumina \u017e\u00edly, sn\u00ed\u017een\u00ed pr\u016ftoku a k intralumin\u00e1ln\u00ed tromb\u00f3ze. Popsan\u00e9 stenotick\u00e9 zm\u011bny se vyskytuj\u00ed p\u0159edev\u0161\u00edm na anastom\u00f3z\u00e1ch.Je z\u0159ejm\u00e9, \u017ee funk\u010dn\u00ed \u017eiln\u00ed graft vy\u017eaduje poopera\u010dn\u00ed sledov\u00e1n\u00ed, proto\u017ee pokud dojde k jeho uz\u00e1v\u011bru a o\u0161et\u0159en\u00ed trombektomi\u00ed, je jeho dal\u0161\u00ed jednolet\u00e1 funkce zachov\u00e1na jen u 30% nemocn\u00fdch. Poopera\u010dn\u00ed sledov\u00e1n\u00ed se skl\u00e1d\u00e1 z anamnestick\u00e9ho vy\u0161et\u0159en\u00ed (obnoven\u00ed klaudikac\u00ed, klidov\u00e9 bolesti), fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed (perifern\u00ed pulzace, ABI) a z radiologick\u00fdch metod, jako je barevn\u00e1 duplexn\u00ed sonografie. Barevn\u00e1 duplexn\u00ed sonografie zhodnot\u00ed pr\u016ftok v jednotliv\u00fdch et\u00e1\u017e\u00edch, umo\u017en\u00ed v\u010das rozpoznat vznik sten\u00f3z a lze j\u00ed sledovat dynamiku v\u00fdvoje patologick\u00e9ho n\u00e1lezu. Sledov\u00e1n\u00ed pomoc\u00ed barevn\u00e9 duplexn\u00ed sonografie a navazuj\u00edc\u00ed o\u0161et\u0159en\u00ed bypassu zlep\u0161ilo dlouhodob\u00e9 funkce o 15%. P\u0159i nejasn\u00e9m n\u00e1lezu je nutn\u00e9 vy\u0161et\u0159it cel\u00e9 \u0159e\u010di\u0161t\u011b (p\u0159\u00edtok, bypass, v\u00fdtok) angiograficky (NMR ag).<\/p>\n<h6>UM\u011aL\u00c9 C\u00c9VN\u00cd N\u00c1HRADY<\/h6>\n<p style=\"text-align: justify;\"><strong>Autologn\u00ed n\u00e1hrady<\/strong> jsou limitov\u00e1ny ve sv\u00e9m mno\u017estv\u00ed, kvalit\u011b a kalibru. V c\u00e9vn\u00ed chirurgii se proto pou\u017e\u00edvaj\u00ed um\u011bl\u00e9 c\u00e9vn\u00ed n\u00e1hrady. P\u016fvodn\u00ed materi\u00e1ly byly objeveny v obdob\u00ed druh\u00e9 sv\u011btov\u00e9 v\u00e1lky a jedn\u00e1 se o polytetrafluoroetylen (PTFE, teflon) a polyetylenterfl\u00e1t (PET, dacron).<\/p>\n<p style=\"text-align: justify;\"><strong>Dacronov\u00e9 (PET prot\u00e9zy)<\/strong> se v c\u00e9vn\u00ed chirurgii pou\u017e\u00edvaj\u00ed ve form\u011b pleten\u00fdch prot\u00e9z. Jsou to por\u00e9zn\u00ed trubice r\u016fzn\u00e9ho kalibru. Prvn\u00ed generace t\u011bchto prot\u00e9z vy\u017eadovala \u201ep\u0159edsr\u00e1\u017een\u00ed\u201c. Prot\u00e9za musela b\u00fdt p\u0159ed implantac\u00ed namo\u010dena do neheparinizovan\u00e9 krve\u00a0nemocn\u00e9ho, krev se v prot\u00e9ze vysr\u00e1\u017eela a prot\u00e9za se stala neprody\u0161nou. V\u011bt\u0161ina dne\u0161n\u00edch pleten\u00fdch prot\u00e9z tento krok nevy\u017eaduje, proto\u017ee jsou impregnov\u00e1ny \u017eelatinou, kolagenem nebo albuminem. Jednou z modifikac\u00ed jsou prot\u00e9zy s impregancemi solemi st\u0159\u00edbra, kter\u00e9 sni\u017euj\u00ed riziko infekce graftu.<\/p>\n<p style=\"text-align: justify;\"><strong>Prot\u00e9zy z PTFE<\/strong> jsou d\u00e1le zpracov\u00e1ny (protla\u010dov\u00e1ny) v expandovan\u00fd PTFE (ePTFE) a prot\u00e9za nen\u00ed pleten\u00e1, ale \u201elit\u00e1\u201c. Struktura jej\u00ed st\u011bny m\u00e1 vy\u0161\u0161\u00ed porozitu ne\u017e dacron, ale p\u00f3ry jsou men\u0161\u00ed ne\u017e u pleten\u00fdch prot\u00e9z. St\u011bna je hydrofobn\u00ed, br\u00e1n\u00ed pr\u016fniku krve a nen\u00ed pot\u0159ebn\u00e9 p\u0159edsr\u00e1\u017een\u00ed. Ke sn\u00ed\u017een\u00ed trombogenity st\u011bny prot\u00e9z se u n\u011bkter\u00fdch model\u016f impregnuje vnit\u0159n\u00ed plocha heparinem.<\/p>\n<p style=\"text-align: justify;\"><strong>Indikace k pou\u017eit\u00ed um\u011bl\u00fdch c\u00e9vn\u00edch n\u00e1hrad.<br \/>\n<\/strong>Oba typy prot\u00e9z jsou vhodn\u00e9 k rekonstruk\u010dn\u00edm v\u00fdkon\u016fm v oblasti aorty a p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b. V infrainguin\u00e1ln\u00ed oblasti se pou\u017e\u00edvaj\u00ed (pokud nen\u00ed vhodn\u00e1 safena) pro proxim\u00e1ln\u00ed femoropoplite\u00e1ln\u00ed bypass (nad koleno) ePTFE prot\u00e9zy s heparinem. Pro oblast pod kolenn\u00edm kloubem (III. \u00fasek poplite\u00e1ln\u00ed arterie a b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b) se doporu\u010duje ePTFE s dist\u00e1ln\u00ed anastom\u00f3zou pomoc\u00ed \u017eiln\u00ed man\u017eety. \u017diln\u00ed man\u017eeta (cuff ) m\u00e1 n\u011bkolik modifikac\u00ed a vlastn\u011b se jedn\u00e1 o kr\u00e1tk\u00fd \u017eiln\u00ed \u00fasek vlo\u017een\u00fd mezi c\u00e9vn\u00ed prot\u00e9zu a arterii. \u017diln\u00ed \u00fasek zlep\u0161uje pr\u016ftok anastom\u00f3zou, proto\u017ee \u017e\u00edla m\u00e1 lep\u0161\u00ed compliance s arteri\u00ed ne\u017e prot\u00e9za a sou\u010dasn\u011b je men\u0161\u00ed v\u00fdskyt sten\u00f3z anastom\u00f3zy.Um\u011bl\u00e9 c\u00e9vn\u00ed n\u00e1hrady se pou\u017e\u00edvaj\u00ed u extranatomick\u00fdch bypass\u016f (axilofemor\u00e1ln\u00ed, axiloaxil\u00e1rn\u00ed). Typ pou\u017eit\u00e9 prot\u00e9zy je d\u00e1n zvykem pracovi\u0161t\u011b, v\u00fdsledky jsou velmi podobn\u00e9. C\u00e9vn\u00ed prot\u00e9zy se pou\u017e\u00edvaj\u00ed i v \u017eiln\u00ed chirurgii, maj\u00ed \u010dasto velk\u00fd pr\u016fsvit, nap\u0159. pro n\u00e1hradu doln\u00ed nebo horn\u00ed dut\u00e9 \u017e\u00edly.Ne\u017e\u00e1douc\u00ed komplikac\u00ed je uz\u00e1v\u011br graftu. \u010casn\u00e9 uz\u00e1v\u011bry jsou nej\u010dast\u011bji zp\u016fsobeny technickou chybou nebo z celkov\u00fdch p\u0159\u00ed\u010din trombofiln\u00edm stavem. P\u0159\u00ed\u010dinou pozdn\u00edch uz\u00e1v\u011br\u016f je hyperplazie intimy na anastom\u00f3z\u00e1ch nebo progrese aterosklerotick\u00e9ho procesu, kdy se zhor\u0161uje kvalita p\u0159\u00edtokov\u00e9ho nebo v\u00fdtokov\u00e9ho traktu.Je dlouhodobou snahou zlep\u0161it kvalitu prot\u00e9z o\u0161et\u0159en\u00edm jejich vnit\u0159n\u00ed plochy, aby vznikla jejich \u201etromborezistence\u201c. Tyto prot\u00e9zy se ozna\u010duj\u00ed jako biofunk\u010dn\u00ed c\u00e9vn\u00ed prot\u00e9zy a k o\u0161et\u0159en\u00ed se pou\u017e\u00edv\u00e1 nap\u0159. uhl\u00edk (carbon coating), heparin, kysli\u010dn\u00edk dusn\u00fd na nosi\u010di nebo antigregancia (prostaglandiny, dipyridamol).Dlouhodobou pr\u016fchodnost graft\u016f na perifern\u00edm arteri\u00e1ln\u00edm \u0159e\u010di\u0161ti signifikantn\u011b zlep\u0161uje farmakoterapie. Doporu\u010duje se antiagrega\u010dn\u00ed terapie aspirinem v d\u00e1vce 100mg\/den nebo clopidogrelem v d\u00e1vce 75mg\/den. U nemocn\u00fdch s vysok\u00fdm rizikem uz\u00e1v\u011bru je metodou volby kombinace antiagrega\u010dn\u00ed a antikoagula\u010dn\u00ed terapie. Warfarin zvy\u0161uje \u00fa\u010dinnost l\u00e9\u010dby, ale sou\u010dasn\u011b zvy\u0161uje riziko masivn\u00edho krv\u00e1cen\u00ed na dvojn\u00e1sobek.<\/p>\n<p style=\"text-align: justify;\"><strong>Biologick\u00e9 c\u00e9vn\u00ed n\u00e1hrady<\/strong>: ide\u00e1ln\u00ed c\u00e9vn\u00ed n\u00e1hrada se po\u0159\u00e1d hled\u00e1 \u2013 m\u011bla by b\u00fdt snadno dostupn\u00e1, se snadnou manipulac\u00ed (handling), rezistentn\u00ed k tromb\u00f3ze a infekci. Z\u00e1sadn\u00ed roli hraje tak\u00e9 cena. V z\u00e1sad\u011b tedy neexistuje materi\u00e1l, kter\u00fd by se sv\u00fdmi vlastnostmi podobal vlastn\u00ed arterii. Pou\u017e\u00edv\u00e1 se \u010derstv\u00fd arteri\u00e1ln\u00ed nebo ven\u00f3zn\u00ed alograft. D\u00e1rce mus\u00ed b\u00fdt ABO-kompatibiln\u00ed, p\u0159esto je t\u0159eba po\u010d\u00edtat s imunitn\u00ed reakc\u00ed a p\u0159\u00edjemce mus\u00ed b\u00fdt imunosuprimov\u00e1n. Dostupnost \u010derstv\u00e9ho alograftu je limitov\u00e1na po\u010dtem d\u00e1rc\u016f. Alografty podl\u00e9haj\u00ed degenerativn\u00edm zm\u011bn\u00e1m, kter\u00e9 se projevuj\u00ed vznikem uz\u00e1v\u011br\u016f a v\u00fddut\u00ed. Omezen\u00e1 dostupnost \u010derstv\u00fdch graft\u016f vedla k v\u00fdvoji r\u016fzn\u00fdch prezerva\u010dn\u00edch metod. Nejb\u011b\u017en\u011bj\u0161\u00ed metodou je kryoprezervace. Indikac\u00ed k pou\u017eit\u00ed biologick\u00fdch graft\u016f je kon\u010detinov\u00fd bypass (p\u0159edev\u0161\u00edm na b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b), kdy nen\u00ed k dispozici autologn\u00ed \u017e\u00edla a jsou v\u00fdhrady k pou\u017eit\u00ed um\u011bl\u00e9 c\u00e9vn\u00ed n\u00e1hrady (infekce). Dal\u0161\u00ed indikac\u00ed je n\u00e1hrada infikovan\u00e9 c\u00e9vn\u00ed prot\u00e9zy nebo se na n\u011bkter\u00fdch pracovi\u0161t\u00edch pou\u017e\u00edv\u00e1 jako interpon\u00e1t pro arterioven\u00f3zn\u00ed spojku k hemodial\u00fdze.<\/p>\n<h6>C\u00c9VN\u00cd INFEKCE<\/h6>\n<p style=\"text-align: justify;\">Infekce v c\u00e9vn\u00ed chirurgii ohro\u017euje nemocn\u00e9ho zv\u00fd\u0161enou mortalitou a rizikem amputace kon\u010detiny. Poopera\u010dn\u00ed ran\u00e1 infekce je t\u0159et\u00ed nej\u010dast\u011bj\u0161\u00ed nosokomi\u00e1ln\u00ed infek\u010dn\u00ed komplikac\u00ed v\u016fbec (po pneumonii a infekci mo\u010dov\u00fdch cest). V c\u00e9vn\u00ed chirurgii postihuje 0,5\u20135% nemocn\u00fdch v z\u00e1vislosti na typu a lokalizaci v\u00fdkonu a d\u00e1le na stupni ischemick\u00e9 choroby doln\u00edch kon\u010detin. V\u00fdkony na periferii kon\u010detin a v t\u0159\u00edsle jsou zat\u00ed\u017eeny vy\u0161\u0161\u00edm po\u010dtem infek\u010dn\u00edch komplikac\u00ed ne\u017e v\u00fdkony na abdomin\u00e1ln\u00ed aort\u011b. Etiologick\u00fdm agens jsou nej\u010dast\u011bji S. aureus, enterokoky, E. coli a koagul\u00e1zanegativn\u00ed stafylokoky.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Prevence \u2013 antibiotika<br \/>\n<\/strong>Z\u00e1sadn\u00ed v\u00fdznam m\u00e1 peropera\u010dn\u00ed antibiotick\u00e1 profylaxe. Jej\u00ed v\u00fdznam nar\u016fst\u00e1 p\u0159i pou\u017eit\u00ed um\u011bl\u00fdch c\u00e9vn\u00edch n\u00e1hrad (prot\u00e9z). Peropera\u010dn\u00ed parenter\u00e1ln\u00ed antibiotick\u00e1 profylaxe sni\u017euje v\u00fdskyt jak ran\u00fdch infekc\u00ed,tak v\u00fdskyt \u010dasn\u00fdch infekc\u00ed c\u00e9vn\u00edch prot\u00e9z. Obecn\u011b plat\u00ed, \u017ee sta\u010d\u00ed jedna intraven\u00f3zn\u00ed d\u00e1vka antibiotikapodan\u00e1 na za\u010d\u00e1tku v\u00fdkonu (\u00favod do anestezie). P\u0159i del\u0161\u00edch opera\u010dn\u00edch v\u00fdkonech, zvl\u00e1\u0161t\u011b pokud byl dopl\u0148ov\u00e1n objem, m\u00e1 smysl pod\u00e1n\u00ed druh\u00e9 d\u00e1vky po 3\u20135hodin\u00e1ch. Protektivn\u00ed efekt antibiotick\u00e9 profylaxe je opakovan\u011b potvrzen, ale jej\u00ed prodlou\u017een\u00ed nad 24 hodin nem\u00e1 \u017e\u00e1dn\u00fd pozitivn\u00ed efekt. K profylaxi v c\u00e9vn\u00ed chirurgii jsou nej\u010dast\u011bji doporu\u010dov\u00e1ny cefalosporiny 2. generace. Typ antibiotika k profylaxi by m\u011blo ur\u010dit\u00a0antibiotick\u00e9 centrum na z\u00e1klad\u011b aktu\u00e1ln\u00edho stavu nosokomi\u00e1ln\u00edch infekc\u00ed v za\u0159\u00edzen\u00ed.<br \/>\nP\u0159i pr\u016fkazu infekce je antibiotick\u00e1 l\u00e9\u010dba vedena na z\u00e1klad\u011b mikrobiologick\u00e9ho n\u00e1lezu (kultivace a citlivost na antibiotika). C\u00edlen\u00e1 antibiotick\u00e1 l\u00e9\u010dba m\u00e1 p\u0159edev\u0161\u00edm v\u00fdznam u infikovan\u00e9 c\u00e9vn\u00ed prot\u00e9zy.<\/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 9a:<br \/>\nc\u00e9vn\u00ed prot\u00e9za \u2013 infekce<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\"><b>C\u00e9vn\u00ed prot\u00e9za \u2013 infekce \u2013 klinika<\/b><\/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_278.png\"><img decoding=\"async\" title=\"Stav po AF bypassu vpravo a cross-ocer bypass, p\u00ed\u0161t\u011bl v t\u0159\u00edsle\" alt=\"Stav po AF bypassu vpravo a cross-ocer bypass, p\u00ed\u0161t\u011bl v t\u0159\u00edsle\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_278.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Stav po AF bypassu vpravo a crossocer bypass, p\u00ed\u0161t\u011bl v t\u0159\u00edsle<\/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_281.png\"><img decoding=\"async\" title=\"Dtto detail\" alt=\"Dtto detail\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_281.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Dtto detail<\/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_279.png\"><img decoding=\"async\" title=\"Detail p\u00ed\u0161t\u011ble\" alt=\"Detail p\u00ed\u0161t\u011ble\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_279.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Detail p\u00ed\u0161t\u011ble<\/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_282.png\"><img decoding=\"async\" title=\"Periferie kon\u010detin\" alt=\"Periferie kon\u010detin\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_282.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Periferie kon\u010detin<\/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_280.png\"><img decoding=\"async\" title=\"Nekr\u00f3za palce\" alt=\"Nekr\u00f3za palce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_280.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Nekr\u00f3za palce<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\u00a0<strong>MR ag, infekce<\/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_284.gif\"><img decoding=\"async\" title=\"NMR ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b, uzav\u0159eno ilick\u00e9 \u0159e\u010di\u0161t\u011b vlevo, cross- -over bypass\" alt=\"NMR ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b, uzav\u0159eno ilick\u00e9 \u0159e\u010di\u0161t\u011b vlevo, cross- -over bypass\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_284.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">NMR ag p\u00e1nevn\u00edho \u0159e\u010di\u0161t\u011b, uzav\u0159eno ilick\u00e9 \u0159e\u010di\u0161t\u011b vlevo, cross<br \/>over bypass<\/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_286.gif\"><img decoding=\"async\" title=\"DTTO \u0161ikm\u00e1 projekce\" alt=\"DTTO \u0161ikm\u00e1 projekce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_286.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">DTTO \u0161ikm\u00e1 projekce<\/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_285.gif\"><img decoding=\"async\" title=\"Zobrazen\u00ed \u0159e\u010di\u0161t\u011b stehen\" alt=\"Zobrazen\u00ed \u0159e\u010di\u0161t\u011b stehen\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_285.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Zobrazen\u00ed \u0159e\u010di\u0161t\u011b stehen<\/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_287.gif\"><img decoding=\"async\" title=\"B\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b, vlevo kontaminace \u017eiln\u00edho syst\u00e9mu kontrastem\" alt=\"B\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b, vlevo kontaminace \u017eiln\u00edho syst\u00e9mu kontrastem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_287.gif\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">B\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b, vlevo kontaminace \u017eiln\u00edho syst\u00e9mu kontrastem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\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_289.jpg\"><img decoding=\"async\" title=\"PET\/CT, akumulace radioaktivity v prav\u00e9m t\u0159\u00edsle\" alt=\"PET\/CT, akumulace radioaktivity v prav\u00e9m t\u0159\u00edsle\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_289.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">PET\/CT, akumulace radioaktivity v prav\u00e9m t\u0159\u00edsle<\/p><\/div>\n<p><strong>Diagn\u00f3za<\/strong><br \/>\nDiagn\u00f3za infikovan\u00e9 c\u00e9vn\u00ed prot\u00e9zy je v\u011bt\u0161inou d\u00e1na klinick\u00fdm n\u00e1lezem. Klasick\u00e9 projevy infekce jsou zarudnut\u00ed r\u00e1ny, obna\u017een\u00ed prot\u00e9zy, p\u00ed\u0161t\u011ble, krv\u00e1cen\u00ed z anastom\u00f3zy a sepse. Lok\u00e1ln\u00ed n\u00e1lez m\u016f\u017ee b\u00fdt u n\u011bkter\u00fdch nemocn\u00fdch velmi diskr\u00e9tn\u00ed \u2013 otok bez zarudnut\u00ed, periprotetick\u00e1 tekutina, uz\u00e1v\u011br graftu, pseudov\u00fddut\u011b a dilatace. Mikrobiologick\u00fd n\u00e1lez p\u0159i punkc\u00ed b\u00fdv\u00e1 negativn\u00ed. Vy\u0161et\u0159en\u00ed obecn\u00fdch marker\u016f infekce (leukocyty a CRP) m\u016f\u017ee b\u00fdt negativn\u00ed, ale jejich absence infekci nevylu\u010duje. Obykl\u00fd obraz infek\u010dn\u00ed komplikace lze sp\u00ed\u0161e o\u010dek\u00e1vat u \u010dasn\u00fdch infekci, pozdn\u00ed infekce graftu maj\u00ed \u010dasto jen mal\u00e9 klinick\u00e9 p\u0159\u00edznaky (fotogalerie 9a).\u00a0P\u0159edm\u011btem diskuz\u00ed je v\u00fdznam st\u011bru z r\u00e1ny na mikrobiologick\u00e9 vy\u0161et\u0159en\u00ed. R\u00e1na b\u00fdv\u00e1 kolonizov\u00e1na z okol\u00ed, v\u011bt\u0161\u00ed v\u00fdznam m\u016f\u017ee m\u00edt punkce s odb\u011brem materi\u00e1lu \u2013 i v t\u011bchto p\u0159\u00edpadech je a\u017e 25% odb\u011br\u016f nehodnotiteln\u00fdch nebo fale\u0161n\u011b negativn\u00edch.Z\u00e1sadn\u00ed v\u00fdznam m\u00e1 sonografie, kter\u00e1 m\u016f\u017ee prok\u00e1zat pseudov\u00fddut\u011b, abscesy nebo tekutinov\u00e9 formace. Tato metoda je lokalizuje, zhodnot\u00ed a umo\u017en\u00ed c\u00edlenou punkci. Duplexn\u00ed vy\u0161et\u0159en\u00ed prok\u00e1\u017ee turbulentn\u00ed tok p\u0159i sten\u00f3z\u00e1ch \u0159e\u010di\u0161t\u011b, kter\u00e9 mohou b\u00fdt d\u016fsledkem trombotick\u00fdch komplikac\u00ed p\u0159i infekci.Dal\u0161\u00ed radiologick\u00e1 vy\u0161et\u0159en\u00ed (NMR ag, CT, fistulografie) mohou pomoci p\u0159i stanoven\u00ed diagn\u00f3zy. Angiografick\u00fd n\u00e1lez umo\u017en\u00ed v rozvaze stanovit mo\u017enosti rekonstruk\u010dn\u00edho v\u00fdkonu. V pr\u016fkazu infek\u010dn\u00ed komplikace, p\u0159edev\u0161\u00edm u chronick\u00fdch infekc\u00ed c\u00e9vn\u00ed prot\u00e9zy, m\u00e1 v\u00fdznam PET\/CT. Metoda je limitov\u00e1na v\u00fdkony na sledovan\u00e9m \u0159e\u010di\u0161ti \u2013 opera\u010dn\u00ed v\u00fdkon p\u0159edstavuje trauma s odpov\u00eddaj\u00edc\u00ed z\u00e1n\u011btlivou reakc\u00ed a typ z\u00e1n\u011btu (traumatick\u00fd \u00d7 infek\u010dn\u00ed) PET\/CT nerozli\u0161\u00ed. P\u0159edpokl\u00e1dan\u00e9 hojen\u00ed opera\u010dn\u00ed r\u00e1ny, a t\u00edm fale\u0161n\u00e1 pozitivita PET\/CT je 3 m\u011bs\u00edce.Infekce endovaskul\u00e1rn\u00edho stentgraftu se projev\u00ed obrazem bakteri\u00e9mie, sepse nebo perifern\u00edmi embolizacemi. Vy\u0161et\u0159en\u00ed PET\/CT m\u00e1 za v\u00fd\u0161e uveden\u00fdch podm\u00ednek sv\u016fj v\u00fdznam.<\/li>\n<li style=\"text-align: justify;\">Terapeutick\u00e9 mo\u017enosti p\u0159i infekci c\u00e9vn\u00ed prot\u00e9zy Infikovan\u00e1 c\u00e9vn\u00ed prot\u00e9za p\u0159edstavuje i v dne\u0161n\u00ed dob\u011b z\u00e1sadn\u00ed probl\u00e9m v c\u00e9vn\u00ed chirurgii. Pokus zachr\u00e1nit infikovanou prot\u00e9zu lok\u00e1ln\u00edm v\u00fdkonem je opodstatn\u011bn\u00fd jen u \u010dasn\u00fdch a ohrani\u010den\u00fdch infekc\u00ed nebo u nemocn\u00fdch s vysok\u00fdm opera\u010dn\u00edm rizikem. Samotn\u00e1 \u00a0antibiotick\u00e1 terapie je bez efektu, podtlakov\u00e1 terapie je sp\u00ed\u0161e pomocn\u00fdm postupem, kter\u00fd m\u016f\u017ee m\u00edt efekt u prot\u00e9z, kter\u00e9 maj\u00ed dlouhodobou ochranu p\u0159ed infekc\u00ed (antimikrobi\u00e1ln\u00ed povrch).Za standardn\u00ed postup p\u0159i infekci c\u00e9vn\u00ed prot\u00e9zy se pova\u017euje jej\u00ed odstran\u011bn\u00ed a <b>extraanatomick\u00e1 rekonstrukce <\/b>pomoc\u00ed autologn\u00edho, homologn\u00edho, heterologn\u00edho nebo aloplastick\u00e9ho materi\u00e1lu (nov\u00fd bypass je ulo\u017een ve zdrav\u00e9 tk\u00e1ni). Reinfekce se vyskytuje ve 2\u20134,5%, ale mortalita je 12\u201325%. Extranatomick\u00e1 rekonstrukce m\u00e1 sv\u00e1 rizika, kter\u00e1 vypl\u00fdvaj\u00ed z jej\u00ed lokalizace: tromb\u00f3zy v d\u016fsledku n\u00edzk\u00e9ho pr\u016ftoku, n\u00edzk\u00e1 dlouhodob\u00e1 pr\u016fchodnost, ruptura pah\u00fdlu aorty nebo infekce podko\u017en\u011b ulo\u017een\u00e9ho implant\u00e1tu.P\u0159\u00edkladem m\u016f\u017ee b\u00fdt infikovan\u00e1 bifurka\u010dn\u00ed aortobifemor\u00e1ln\u00ed prot\u00e9za. Ta se vyjme, pah\u00fdl aorty se za\u0161ije a revaskularizace doln\u00edch kon\u010detin se provede extranatomick\u00fdm axilobifemor\u00e1ln\u00edm bypassem, kter\u00fd je ulo\u017een v podko\u017e\u00ed hrudn\u00edku.Alternativou extranatomick\u00e9 rekonstrukce je <b>in situ rekonstrukce<\/b>, kdy se infikovan\u00e1 prot\u00e9za vyjme a do stejn\u00e9 lokalizace se ulo\u017e\u00ed nov\u00fd bypass. Nen\u00ed v\u0161ak z\u0159ejm\u00e9, \u017ee by odstranila nev\u00fdhody rozs\u00e1hl\u00e9 extranatomick\u00e9 rekonstrukce. V\u00fdsledky r\u016fzn\u00fdch pracovi\u0161\u0165 prokazuj\u00ed, \u017ee je ni\u017e\u0161\u00ed po\u010det reinfekc\u00ed a ni\u017e\u0161\u00ed mortalita (8\u201310%). Jako biologick\u00fd materi\u00e1l se pou\u017e\u00edv\u00e1 hlubok\u00e1 stehenn\u00ed \u017e\u00edla a homografty. Pou\u017eit\u00ed hlubok\u00e9 stehenn\u00ed \u017e\u00edly je spojeno s jej\u00edm pracn\u00fdm odb\u011brem a v\u011bt\u0161\u00edm opera\u010dn\u00edm traumatem. Pou\u017eit\u00ed homograftu je limitov\u00e1no jeho dostupnost\u00ed (kryoprezervovan\u00e9 \u017e\u00edly) a p\u0159edev\u0161\u00edm degenerativn\u00edmi zm\u011bnami. K rekonstrukc\u00edm in situ se tak\u00e9 pou\u017e\u00edvaj\u00ed dacronov\u00e9 prot\u00e9zy. Rovn\u011b\u017e na jejich pou\u017eit\u00ed nen\u00ed jednotn\u00fd n\u00e1zor, ale v\u00fdsledky t\u011bchto rekonstrukc\u00ed oprav\u0148uj\u00ed k jejich pou\u017eit\u00ed.V podstat\u011b se pou\u017e\u00edvaj\u00ed 3 typy dacronov\u00fdch prot\u00e9z: prot\u00e9za m\u00e1 kolagenovou vrstvu, kter\u00e1 obsahuje acet\u00e1t st\u0159\u00edbra, prot\u00e9za obsahuje \u010dist\u00e9 st\u0159\u00edbro, kter\u00e9 bylo naneseno do jej\u00ed st\u011bny, nebo se jedn\u00e1 o dacronov\u00e9 prot\u00e9zy s kolagenem a s rifampicinem (p\u0159ed implantac\u00ed jsou namo\u010deny do roztoku s rifampicinem).<\/li>\n<li style=\"text-align: justify;\">Dacronov\u00e9 prot\u00e9zy s acet\u00e1tem st\u0159\u00edbra \u2013 metoda vyu\u017e\u00edv\u00e1 antibakteri\u00e1ln\u00ed vlastnosti st\u0159\u00edbra, kter\u00e9 ni\u010d\u00ed bakterie jak v klidov\u00e9, tak mitotick\u00e9 f\u00e1zi. Tento du\u00e1ln\u00ed \u00fa\u010dinek se vysv\u011btluje absenc\u00ed resistence proti \u00fa\u010dinku st\u0159\u00edbra.<br \/>\nProtektivn\u00ed \u00fa\u010dinek acet\u00e1tu st\u0159\u00edbra p\u0159etrv\u00e1v\u00e1 4 t\u00fddny. Po uplynut\u00ed t\u00e9to doby se chov\u00e1 ji\u017e jako b\u011b\u017en\u00e1 dacronov\u00e1 prot\u00e9za. Z toho vypl\u00fdv\u00e1, \u017ee p\u0159i p\u0159etrv\u00e1n\u00ed potenci\u00e1ln\u00edho zdroje infekce (nap\u0159. defekt DKK) je nutn\u00e1 dlouhodob\u00e1 antibiotick\u00e1 terapie. Po vyjmut\u00ed infikovan\u00e9 c\u00e9vn\u00ed prot\u00e9zy a jej\u00edm nahrazen\u00ed in situ pomoc\u00ed prot\u00e9zy s acet\u00e1tem st\u0159\u00edbra je v\u00fdskyt reinfekce v 10%. Parci\u00e1ln\u00ed explantace infikovan\u00e9 prot\u00e9zy je spojena s vysok\u00fdm rizikem reinfekce a tato metoda je ur\u010dena je pro v\u00fdjime\u010dn\u00e9 situace.<\/li>\n<li style=\"text-align: justify;\">St\u0159\u00edbrem vaporizovan\u00e9 dacronov\u00e9 prot\u00e9zy maj\u00ed dlouhodob\u00fd antimikrobi\u00e1ln\u00ed efekt. Bylo zji\u0161t\u011bno, \u017ee po roce od implantace bylo na plo\u0161e prot\u00e9zy prok\u00e1z\u00e1no je\u0161t\u011b 98% st\u0159\u00edbra. Jejich pou\u017e\u00edv\u00e1n\u00ed je zat\u00edm ve stadiu prvn\u00edch nad\u011bjn\u00fdch v\u00fdsledk\u016f. P\u0159i prok\u00e1zan\u00e9 lok\u00e1ln\u00ed reinfekci se prok\u00e1zal p\u0159\u00edzniv\u00fd efekt podtlakov\u00e9 terapie (VAC = vacuum assisted closure) na vhojen\u00ed tohoto typu prot\u00e9zy.<\/li>\n<li style=\"text-align: justify;\">Dal\u0161\u00edm modelem jsou dacronov\u00e9 prot\u00e9zy jen nas\u00e1kl\u00e9 rifampicinem, kter\u00e9 maj\u00ed dobr\u00e9 v\u00fdsledky u in situ rekonstrukc\u00ed. O\u0161et\u0159en\u00ed prot\u00e9zy rifampicinem se prov\u00e1d\u00ed t\u011bsn\u011b p\u0159ed jej\u00ed implantac\u00ed na opera\u010dn\u00edm s\u00e1le. Nev\u00fdhodou jsou reinfekce MRSA, relativn\u011b kr\u00e1tk\u00e1 doba \u00fa\u010dinku fampicinu a limitovan\u00e9 pou\u017eit\u00ed u gramnegativn\u00edch bakteri\u00ed. Rifampicin \u00fasp\u011b\u0161n\u011b potla\u010duje infekce S. aureus a epidermidis.<br \/>\nProblematiku infikovan\u00fdch c\u00e9vn\u00edch prot\u00e9z lze shrnout: nez\u00e1visle na druhu pou\u017eit\u00e9 c\u00e9vn\u00ed n\u00e1hrady je po odstran\u011bn\u00ed infikovan\u00e9 c\u00e9vn\u00ed prot\u00e9zy t\u0159eba respektovat pravidla septick\u00e9 chirurgie. Jedn\u00e1 se o lok\u00e1ln\u00ed o\u0161et\u0159en\u00ed (debridement) r\u00e1ny a celkov\u00e9 pod\u00e1v\u00e1n\u00ed antibiotik. Lok\u00e1ln\u00ed terapie antibiotiky a antiseptiky dopl\u0148uje celkovou l\u00e9\u010dbu. Od celkov\u00e9 antibiotick\u00e9 l\u00e9\u010dby se o\u010dek\u00e1v\u00e1 sn\u00ed\u017een\u00ed rizika uchycen\u00ed bakteri\u00ed na nov\u011b implantovanou prot\u00e9zu. Po o\u0161et\u0159en\u00ed prot\u00e9zy v retroperitoneu m\u00e1 p\u0159\u00edzniv\u00fd vliv pro jej\u00ed vhojen\u00ed p\u0159ekryt\u00ed prot\u00e9zy vit\u00e1ln\u00ed tk\u00e1n\u00ed, nap\u0159. omentem nebo svalov\u00fdm lalokem. P\u0159i pou\u017eit\u00ed prot\u00e9zy se solemi st\u0159\u00edbra se doporu\u010duje (a tak\u00e9 se pou\u017e\u00edv\u00e1) tuto prot\u00e9zu je\u0161t\u011b nasytit roztokem rifampicinu k vyvol\u00e1n\u00ed synergn\u00edho efektu.Infikovan\u00e1 c\u00e9vn\u00ed prot\u00e9za by m\u011bla b\u00fdt chirurgicky o\u0161et\u0159ena \u2013 v cel\u00e9m rozsahu vyjmuta. K jej\u00ed n\u00e1hrad\u011b je nejvhodn\u011bj\u0161\u00ed in situ bypass pomoc\u00ed autologn\u00edho materi\u00e1lu, kter\u00fd je nejodoln\u011bj\u0161\u00ed k reinfekci. Metodou volby jsou extranatomick\u00e9 bypassy neinfikovan\u00fdm prost\u0159ed\u00edm nebo lze pou\u017e\u00edt homografty. Dobr\u00e9 v\u00fdsledky prokazuje pou\u017eit\u00ed dacronov\u00fdch prot\u00e9z, kter\u00e9 byla antimikrobi\u00e1ln\u011b o\u0161et\u0159eny solemi st\u0159\u00edbra, rifampicinem nebo oboj\u00edm. Pou\u017eit\u00ed dacronov\u00fdch prot\u00e9z m\u00e1 sv\u00e9 opodstatn\u011bn\u00ed, p\u0159edev\u0161\u00edm u nemocn\u00fdch, kdy nen\u00ed k dispozici autologn\u00ed materi\u00e1l nebo kdy je jeho pou\u017eit\u00ed spojeno s vy\u0161\u0161\u00edm opera\u010dn\u00edm rizikem.Konzervativn\u00ed terapie infikovan\u00e9 prot\u00e9zy pomoc\u00ed dren\u00e1\u017ee, proplach\u016f a antibiotik je ur\u010dena jen pro nemocn\u00e9 s vysok\u00fdm opera\u010dn\u00edm rizikem. Mo\u017enosti lok\u00e1ln\u00ed chirurgick\u00e9 l\u00e9\u010dby nyn\u00ed roz\u0161i\u0159uje podtlakov\u00e1 terapie (VAC).<\/li>\n<\/ul>\n<h6>ZAJI\u0160T\u011aN\u00cd DLOUHODOB\u00c9HO C\u00c9VN\u00cdHO P\u0158\u00cdSTUPU \u2013 ZAVEDEN\u00cd PORTU<\/h6>\n<p style=\"text-align: justify;\">Terapie onkologick\u00fdch onemocn\u011bn\u00ed vy\u017eaduje zaji\u0161t\u011bn\u00ed dlouhodob\u00e9ho a bezpe\u010dn\u00e9ho \u017eiln\u00edho p\u0159\u00edstupu. Pomineme-li \u017eiln\u00ed p\u0159\u00edstup perifern\u00edm \u0159e\u010di\u0161t\u011bm, kter\u00fd velmi rychle podko\u017en\u00ed \u017eiln\u00ed \u0159e\u010di\u0161t\u011b ni\u010d\u00ed, p\u0159ich\u00e1z\u00ed v \u00favahu kanylace centr\u00e1ln\u00edho \u017eiln\u00edho syst\u00e9mu nebo pou\u017eit\u00ed implantabiln\u00edho syst\u00e9mu \u2013 portu. Jeho z\u00e1sadn\u00ed v\u00fdhodou je, \u017ee cel\u00fd syst\u00e9m je ulo\u017een do podko\u017e\u00ed. Technika portu je pou\u017eiteln\u00e1 i mimo \u017eiln\u00ed \u0159e\u010di\u0161t\u011b a jeho cestou lze zajistit permanentn\u00ed vstup tak\u00e9 do arteri\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b, do peritone\u00e1ln\u00ed dutiny a epidur\u00e1ln\u00edho prostoru. Vyu\u017eit\u00ed portu p\u0159evl\u00e1d\u00e1 v \u017eiln\u00edm p\u0159\u00edstupu (90%), asi 5% implantovan\u00fdch port\u016f je ur\u010deno pro arteri\u00e1ln\u00ed p\u0159\u00edstup a 5% port\u016f u nemocn\u00fdch k p\u0159\u00edstupu do peritone\u00e1ln\u00ed dutiny, subarachnoide\u00e1ln\u00edho nebo epidur\u00e1ln\u00edho prostoru.Z\u00e1kladn\u00ed indikac\u00ed k zaveden\u00ed portu je nutnost dlouhodob\u00e9 chemoterapie. Cytostatika jsou siln\u00e9 kyseliny nebo z\u00e1sady a jejich aplikace do perifern\u00edho \u017eiln\u00edho \u0159e\u010di\u0161t\u011b nejenom v d\u016fsledku traumatu \u017e\u00edly kanylac\u00ed, ale p\u0159edev\u0161\u00edm aplikac\u00ed cytostatika vede k tromb\u00f3ze a n\u00e1sledn\u00e9mu z\u00e1niku p\u0159\u00edstupu.<\/p>\n<p style=\"text-align: justify;\">P\u0159\u00edstup do \u017eiln\u00edho \u0159e\u010di\u0161t\u011b m\u00e1 svou historii a v\u00fdvoj. Stru\u010dn\u011b lze shrnout, \u017ee za\u010d\u00e1tkem 60. let minul\u00e9ho stolet\u00ed byla vyvinuta technika kanylace velk\u00fdch \u017eil a zevn\u00ed arterioven\u00f3zn\u00ed spojka, v polovin\u011b 60. let n\u00e1sledovala intern\u00ed arterioven\u00f3zn\u00ed spojka. Arterioven\u00f3zn\u00ed spojka v t\u00e9to indikace ztratila na v\u00fdznamu, ale vylep\u0161ila se technika kanylac\u00ed centr\u00e1ln\u00edho \u017eiln\u00edho syst\u00e9mu antimikrobi\u00e1ln\u00ed \u00fapravou kanyl a pou\u017eit\u00edm metody tunelizace k jejich ulo\u017een\u00ed do podko\u017e\u00ed. V 80. letech minul\u00e9ho stolet\u00ed potom za\u010dala historie podko\u017en\u00edho \u017eiln\u00edho portu.Podko\u017en\u00ed port je kat\u00e9tr s kom\u016frkou implantovanou do podko\u017e\u00ed. Typ portu je t\u0159eba zv\u00e1\u017eit dle indikace jeho pou\u017eit\u00ed. Nejb\u011b\u017en\u011bj\u0161\u00ed jsou jednokomorov\u00e9 porty s mal\u00fdm pr\u016ftokem ur\u010den\u00e9 pro b\u011b\u017enou chemoterapii solidn\u00edch n\u00e1dor\u016f. Pro speci\u00e1ln\u00ed pou\u017eit\u00ed (parenter\u00e1ln\u00ed v\u00fd\u017eiva, p\u0159evody krevn\u00edch deriv\u00e1t\u016f apod.) jsou v\u00fdhodn\u011bj\u0161\u00ed porty dvoukomorov\u00e9 nebo porty s vysok\u00fdm pr\u016ftokem. Port je tvo\u0159en titanovou kom\u016frkou, kter\u00e1 je kryta silikonovou membr\u00e1nou a zevn\u00edm pouzdrem. Pomoc\u00ed spojovac\u00edho krou\u017eku je kom\u016frka spojena s kat\u00e9trem zaveden\u00fdm do centr\u00e1ln\u00edho \u017eiln\u00edho syst\u00e9mu. Mezi kom\u016frkou a kat\u00e9trem je tzv. v\u00fdstupn\u00ed kanyla. Transkut\u00e1nn\u011b se do kom\u016frky portu pod\u00e1v\u00e1 speci\u00e1ln\u00ed Huberovou jehlou roztok ur\u010den\u00fd k intraven\u00f3zn\u00ed terapii. Pro spr\u00e1vnou funkci portu je kvalita pou\u017eit\u00e9 jehly zcela z\u00e1sadn\u00ed, nesm\u00ed se pou\u017e\u00edt b\u011b\u017en\u00e1 podko\u017en\u00ed jehla, kter\u00e1 u portu po\u0161kozuje jeho membr\u00e1nu a m\u016f\u017ee zp\u016fsobit obstrukci portu. Speci\u00e1ln\u00ed Huberova jehla umo\u017e\u0148uje a\u017e 3000 vpich\u016f do kom\u016frky portu. Jehly se li\u0161\u00ed sv\u00fdm kalibrem a tvarem dle aplikovan\u00e9 l\u00e1tky. Z\u00e1kladn\u00ed indikac\u00ed v pou\u017eit\u00ed \u017eiln\u00edho portu je syst\u00e9mov\u00e1 chemoterapie, dal\u0161\u00edmi indikacemi jsou l\u00e9\u010dba astmatu, antibiotick\u00e1 l\u00e9\u010dba, krevn\u00ed p\u0159evody, parenter\u00e1ln\u00ed v\u00fd\u017eiva. Tepenn\u00fd port je pou\u017e\u00edv\u00e1n v region\u00e1ln\u00ed chemoterapii n\u00e1dor\u016f jater a slinivky b\u0159i\u0161n\u00ed. Peritone\u00e1ln\u00ed port je indikov\u00e1n k region\u00e1ln\u00ed chemoterapii a k vypou\u0161t\u011bn\u00ed ascitu. Epidur\u00e1ln\u00ed nebo spin\u00e1ln\u00ed port je vhodn\u00fd pou\u017e\u00edt k ti\u0161en\u00ed bolesti u termin\u00e1ln\u00edch stav\u016f.K zaveden\u00ed podko\u017en\u00edho portu se pou\u017e\u00edv\u00e1 Seldingerovy nebo chirurgick\u00e9 techniky. Punk\u010dn\u00ed technikou je zaji\u0161t\u011bn p\u0159\u00edstup do horn\u00ed dut\u00e9 \u017e\u00edly cestou kanylace pokl\u00ed\u010dkov\u00e9 nebo jugul\u00e1rn\u00ed \u017e\u00edly. V\u011bt\u0161inou se pou\u017e\u00edv\u00e1 firemn\u00ed implanta\u010dn\u00ed set. Za aseptick\u00fdch podm\u00ednek se v lok\u00e1ln\u00ed anestezii provede punkce centr\u00e1ln\u00ed \u017e\u00edly (nej\u010dast\u011bji podkl\u00ed\u010dkov\u00e1 \u017e\u00edla vpravo), zavede se vodi\u010d a skiaskopicky se provede kontrola polohy zavad\u011b\u010de v horn\u00ed dut\u00e9 \u017e\u00edle. N\u00e1sleduje dilatace kan\u00e1lu, zaveden\u00ed kat\u00e9tru a odstran\u011bn\u00ed vodi\u010de. Po kontrole \u017eiln\u00edho n\u00e1vratu se proplachuje kat\u00e9tr fyziologick\u00fdm roztokem a v pektor\u00e1ln\u00ed krajin\u011b se vytvo\u0159\u00ed prostor pro kom\u016frku. Port se kompletuje a n\u00e1sleduje jeho fixace v podko\u017e\u00ed. Po zaveden\u00ed Hubertovy jehly do kom\u016frky aspirac\u00ed kontrolujeme spr\u00e1vnou funkci syst\u00e9mu. Po uz\u00e1v\u011bru r\u00e1ny n\u00e1sleduje kontroln\u00ed n\u00e1st\u0159ik portu rtg kontrastn\u00ed l\u00e1tkou (kontrola event. \u00faniku l\u00e1tky), provede se proplach portu fyziologick\u00fdm roztokem a pod\u00e1n\u00ed heparinov\u00e9 z\u00e1tky. Alternativn\u00ed je chirurgick\u00e1 prepara\u010dn\u00ed technika. Ta je vhodn\u00e1 p\u0159i znalosti techniky k zaveden\u00ed kat\u00e9tru cestou cefalick\u00e9 \u017e\u00edly po jej\u00ed preparaci v sulcus deltoideopectoralis. Po podvazu periferie \u017e\u00edly se po jej\u00ed tomii zavede kat\u00e9tr za skiaskopick\u00e9 kontroly do horn\u00ed dut\u00e9 \u017e\u00edly. Ko\u017en\u00ed \u0159ez se vyu\u017eije k vytvo\u0159en\u00edpodko\u017en\u00ed kapsy pro kom\u016frku portu (fotogalerie 9b). P\u0159i uz\u00e1v\u011bru hlavn\u00edch \u017eiln\u00edch kmen\u016f horn\u00ed poloviny t\u011bla lze prepara\u010dn\u00ed technikou zav\u00e9st kanylu portu \u0159e\u010di\u0161t\u011bm v. saphena magna nebo p\u00e1nevn\u00edch \u017eil do doln\u00ed dut\u00e9 \u017e\u00edly.<\/p>\n<p style=\"text-align: justify;\">Za kontraindikaci k zaveden\u00ed portu se pova\u017euje neutropenie a trombopenie, bakteri\u00e9mie a septick\u00e9 stavy, t\u011b\u017ek\u00e9 poruchy koagulace a trombofiln\u00ed stavy.Zaveden\u00ed a pou\u017e\u00edv\u00e1n\u00ed podko\u017en\u00edho \u017eiln\u00ed portu m\u016f\u017ee m\u00edt komplikace. Po kanylaci podkl\u00ed\u010dkov\u00e9 \u017e\u00edly m\u016f\u017ee vzniknout pneumotorax (nutn\u00e1 rtg kontrola po 24 hodin\u00e1ch po zaveden\u00ed portu nebo dle klinick\u00e9ho stavu), m\u016f\u017ee doj\u00edt k poru\u0161e funkce portu pro technickou chybu (nap\u0159. zalomen\u00ed nebo \u0161patn\u00e1 poloha kat\u00e9tru). Hematom v m\u00edst\u011b zaveden\u00ed portu je v\u011bt\u0161inou zp\u016fsoben poruchami hemokoagulace. B\u011bhem pou\u017e\u00edv\u00e1n\u00ed portu se mohou vyvinout komplikace, kter\u00e9 jsou indikac\u00ed k vyjmut\u00ed syst\u00e9mu. Jedn\u00e1 se o net\u011bsnost syst\u00e9mu, dekubitus nad portem a nezvl\u00e1dnuteln\u00e9 infek\u010dn\u00ed komplikace. Dal\u0161\u00ed komplikace jsou m\u00edstn\u00ed infekce, kat\u00e9trov\u00e9 sepse a tromb\u00f3zy, kter\u00e9 jsou p\u0159i ne\u00fasp\u011bchu konzervativn\u00ed terapie indikac\u00ed k vyjmut\u00ed portu.Pokud nedojde k poru\u0161e funkce portu, a t\u00edm k pot\u0159eb\u011b jeho vyjmut\u00ed, je indikov\u00e1na jeho extrakce p\u016fl roku po dokon\u010den\u00ed terapie, kdy ji\u017e nen\u00ed p\u0159edpoklad pot\u0159eby p\u0159\u00edstupu do centr\u00e1ln\u00ed \u017e\u00edly.<\/p>\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 9b:<br \/>\nport<\/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_293.png\"><img decoding=\"async\" title=\"Port syst\u00e9m, kanyla, kom\u016frka portu\" alt=\"Port syst\u00e9m, kanyla, kom\u016frka portu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_293.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Port syst\u00e9m, kanyla, kom\u016frka portu<\/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_292.png\"><img decoding=\"async\" title=\"Preparace cefalick\u00e9 \u017e\u00edly v sulcus deltoideopectoralis\" alt=\"Preparace cefalick\u00e9 \u017e\u00edly v sulcus deltoideopectoralis\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_292.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Preparace cefalick\u00e9 \u017e\u00edly v sulcus deltoideopectoralis<\/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_295.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Zaveden\u00ed kanyly portu do \u017e\u00edly\" alt=\"Zaveden\u00ed kanyly portu do \u017e\u00edly\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_295.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Zaveden\u00ed kanyly portu do \u017e\u00edly<\/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_294.png\"><img decoding=\"async\" title=\"P\u0159ipojen\u00ed kom\u016frky portu ke kanyle\" alt=\"P\u0159ipojen\u00ed kom\u016frky portu ke kanyle\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_294.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">P\u0159ipojen\u00ed kom\u016frky portu ke kanyle<\/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_296.png\"><img decoding=\"async\" title=\"Ulo\u017een\u00ed kom\u016frky portu do podko\u017e\u00ed\" alt=\"Ulo\u017een\u00ed kom\u016frky portu do podko\u017e\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_296.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ulo\u017een\u00ed kom\u016frky portu do podko\u017e\u00ed<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"<p>MEDIKAMENT\u00d3ZN\u00cd TERAPIE\u00a0PO C\u00c9VN\u011aCHIRURGICK\u00ddCH V\u00ddKONECH\u00a0A PO ENDOVASKUL\u00c1RN\u00cdCH INTERVENC\u00cdCH Nemocn\u00ed, kte\u0159\u00ed podstoupili v\u00fdkon na c\u00e9vn\u00edm \u0159e\u010di\u0161ti, vy\u017eaduj\u00ed n\u00e1slednou optimalizovanou l\u00e9\u010dbu, kter\u00e1 by m\u011bla modifikovat nebo eliminovat kardiovaskul\u00e1rn\u00ed rizikov\u00e9 faktory, a t\u00edm preventivn\u011b ovlivnit progresi z\u00e1kladn\u00edho v\u011bt\u0161inou aterosklerotick\u00e9ho onemocn\u011bn\u00ed. Doporu\u010den\u00e1 l\u00e9\u010dba vych\u00e1z\u00ed z definic\u00ed American Heart Association a Evropsk\u00e9 spole\u010dnost\u00ed pro kardiologii. Je p\u0159ihl\u00e9dnuto k poznatk\u016fm vypl\u00fdvaj\u00edc\u00edm ze [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":45,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2282","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2282","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=2282"}],"version-history":[{"count":18,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2282\/revisions"}],"predecessor-version":[{"id":2310,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2282\/revisions\/2310"}],"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=2282"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}