{"id":2322,"date":"2013-04-08T10:58:04","date_gmt":"2013-04-08T10:58:04","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2322"},"modified":"2013-06-15T11:32:32","modified_gmt":"2013-06-15T11:32:32","slug":"10-onemocneni-zil-a-lymfatickych-cev","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2322","title":{"rendered":"10 Onemocn\u011bn\u00ed \u017eil a lymfatick\u00fdch c\u00e9v"},"content":{"rendered":"<h6>TERMINOLOGIE<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Chronick\u00e1 \u017eiln\u00ed porucha<\/strong> \u2013 term\u00edn ozna\u010duje cel\u00e9 spektrum morfologick\u00fdch a funk\u010dn\u00edch abnormalit \u017eiln\u00edho syst\u00e9mu (asymptomatick\u00fdch\/symptomatick\u00fdch, l\u00e9\u010den\u00fdch\/nel\u00e9\u010den\u00fdch).<\/li>\n<li style=\"text-align: justify;\"><strong>Chronick\u00e9 \u017eiln\u00ed onemocn\u011bn\u00ed<\/strong> \u2013 jak\u00e1koliv dlouhotrvaj\u00edc\u00ed morfologick\u00e1 a funk\u010dn\u00ed abnormalita \u017eiln\u00edho syst\u00e9mu projevuj\u00edc\u00ed se symptomy a\/nebo zn\u00e1mkami (viditeln\u00fdmi projevy), kter\u00e1 vy\u017eaduje vy\u0161et\u0159en\u00ed a\/nebo l\u00e9\u010dbu.<\/li>\n<li style=\"text-align: justify;\"><strong>Varixy (C1\u2013C2)<\/strong> \u2013 lehk\u00e1 forma chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed, venektazie, retikul\u00e1rn\u00ed a uzlovit\u00e9 varixy.<\/li>\n<li style=\"text-align: justify;\"><strong>Chronick\u00e1 \u017eiln\u00ed insuficience (C3\u2013C6)<\/strong> \u2013 term\u00edn ozna\u010duj\u00edc\u00ed pokro\u010dil\u00e9 formy chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed \u2013 v\u00fdrazn\u00e9 otoky, ko\u017en\u00ed zm\u011bny nebo \u017eiln\u00ed v\u0159edy (floridn\u00ed, zhojen\u00e9).<\/li>\n<li style=\"text-align: justify;\"><strong>PREVAIT<\/strong> \u2013 zkratka znamenaj\u00edc\u00ed PREsence of Varices After InTervention (p\u0159\u00edtomnost rezidu\u00e1ln\u00edch nebo rekurentn\u00edch varix\u016f po l\u00e9\u010db\u011b).<\/li>\n<li style=\"text-align: justify;\"><strong>Rekurentn\u00ed (recidivuj\u00edc\u00ed) varixy<\/strong> \u2013 znovuobjeven\u00ed varix\u016f v oblasti, ze kter\u00e9 byly p\u0159edt\u00edm \u00fasp\u011b\u0161n\u011b odstran\u011bny.<\/li>\n<li style=\"text-align: justify;\"><strong>Rezidu\u00e1ln\u00ed varixy<\/strong> \u2013 varixy, kter\u00e9 z\u016fstaly (byly ponech\u00e1ny) po l\u00e9\u010db\u011b (Eklof, 2009).<\/li>\n<\/ul>\n<h3>10.1 Chronick\u00e1 \u017eiln\u00ed onemocn\u011bn\u00ed\u00a0(\u017eiln\u00ed insuficience)<\/h3>\n<h6>EPIDEMIOLOGIE<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_299.jpg\"><img decoding=\"async\" title=\"Obr. 1 - Krv\u00e1cej\u00edc\u00ed varix\" alt=\"Obr. 1 - Krv\u00e1cej\u00edc\u00ed varix\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_299.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1 Krv\u00e1cej\u00edc\u00ed varix<\/p><\/div>\n<p style=\"text-align: justify;\">\u017diln\u00ed insuficience je nejroz\u0161\u00ed\u0159en\u011bj\u0161\u00ed civiliza\u010dn\u00ed onemocn\u011bn\u00ed, projevuj\u00edc\u00ed se pocity t\u00edhy a bolestmi doln\u00edch kon\u010detin b\u011bhem st\u00e1n\u00ed, ale i v klidu po v\u011bt\u0161\u00ed celodenn\u00ed n\u00e1maze. U\u017e v \u010dasn\u00fdch stadi\u00edch onemocn\u011bn\u00ed se m\u016f\u017ee odpoledne a nave\u010der objevovat otok kolem kotn\u00edk\u016f. Prevalence varix\u016f (st. C1 a C2) u evropsk\u00e9 populace je73,4\u201374,9%, chronick\u00e1 \u017eiln\u00ed insuficience (trofick\u00e9 ko\u017en\u00ed zm\u011bny, st. C4\u2013C6) se objevuje ve 3,6\u20138,6%, p\u0159i\u010dem\u017e zhojen\u00fd \u017eiln\u00ed b\u00e9rcov\u00fd v\u0159ed se vyskytuje u 0,6\u20131,4% populace a floridn\u00ed v\u0159ed p\u0159ibli\u017en\u011b u 0,5% obyvatel Evropy.<\/p>\n<p style=\"text-align: justify;\">Mezi v\u00fdznamn\u00e9 rizikov\u00e9 faktory v sou\u010dasnosti \u0159ad\u00edme vy\u0161\u0161\u00ed v\u011bk, pozitivn\u00ed rodinnou anamn\u00e9zu a po\u010det t\u011bhotenstv\u00ed u \u017een. Pro rizikov\u00e9 faktory, jako je kou\u0159en\u00ed, arteri\u00e1ln\u00ed hypertenze, n\u00edzk\u00e1 fyzick\u00e1\u00a0aktivita nebo chronick\u00e1 z\u00e1cpa, zat\u00edm neexistuje dostate\u010dn\u00e9 mno\u017estv\u00ed v\u011brohodn\u00fdch d\u016fkaz\u016f. Pokud p\u0159isp\u00edvaj\u00ed k rozvoji onemocn\u011bn\u00ed, potom pouze v mal\u00e9 m\u00ed\u0159e.<\/p>\n<h6>ETIOLOGIE<\/h6>\n<p style=\"text-align: justify;\">Spole\u010dn\u00fdmi rysy prim\u00e1rn\u00edch varix\u016f jsou patologick\u00e9 zm\u011bny \u017eiln\u00ed st\u011bny, valvul\u00e1rn\u00ed insuficience a reflux. Prim\u00e1rn\u00ed struktur\u00e1ln\u00ed zm\u011bny a fok\u00e1ln\u00ed dilatace \u017eiln\u00ed st\u011bny postupn\u011b vedou k valvul\u00e1rn\u00ed dysfunkci a k rozvoji refluxu. Ten je n\u00e1sledn\u011b p\u0159\u00ed\u010dinou sekund\u00e1rn\u00edch zm\u011bn \u017eiln\u00ed st\u011bny. Zv\u00fd\u0161en\u00fd \u017eiln\u00ed tlak vyvol\u00e1v\u00e1 zm\u011bny uspo\u0159\u00e1d\u00e1n\u00ed a dysfunkci \u017eiln\u00ed st\u011bny a doch\u00e1z\u00ed k dal\u0161\u00ed dilataci posti\u017een\u00e9 \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;\" rowspan=\"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_301.jpg\"><img decoding=\"async\" title=\"Obr. 2 - Varixy doln\u00edch kon\u010detin\" alt=\"Obr. 2 - Varixy doln\u00edch kon\u010detin\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_301.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<br \/>Varixy doln\u00edch kon\u010detin<\/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_302.jpg\"><img decoding=\"async\" title=\"Obr. 3 - Chronick\u00e1 \u017eiln\u00ed insufi cience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi\" alt=\"Obr. 3 - Chronick\u00e1 \u017eiln\u00ed insufi cience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_302.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>Chronick\u00e1 \u017eiln\u00ed insufi cience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi<br \/>zm\u011bnami k\u016f\u017ee<\/p><\/div><\/td>\n<\/tr>\n<tr>\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_303.jpg\"><img decoding=\"async\" title=\"Obr. 4 - B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insufi cience\" alt=\"Obr. 4 - B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insufi cience\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_303.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4<br \/>B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insufi cience<br \/>ve stadiu C6 \u2013 CVI C6)<\/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_304.jpg\"><img decoding=\"async\" title=\"Obr. 5 - B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na za\u010d\u00e1tku\" alt=\"Obr. 5 - B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na za\u010d\u00e1tku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_304.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na za\u010d\u00e1tku<br \/>l\u00e9\u010dby<\/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_305.jpg\"><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=\"Obr. 6 - B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na konci l\u00e9\u010dby\" alt=\"Obr. 6 - B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na konci l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_305.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na konci<br \/>l\u00e9\u010dby<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.a<\/span><\/p>\n<h6>PATOGENEZE<\/h6>\n<p style=\"text-align: justify;\">Term\u00edn \u017eiln\u00ed insuficience ozna\u010duje neschopnost \u017eiln\u011b-svalov\u00e9 pumpy doln\u00edch kon\u010detin od\u010derpat zp\u011bt k srdci v\u0161echnu do kon\u010detin p\u0159iv\u00e1d\u011bnou krev. M\u011bstnaj\u00edc\u00ed krev vede ke vzniku \u017eiln\u00ed hypertenze. P\u0159\u00ed\u010dinou je reflux, obstrukce nebo jejich kombinace.<\/p>\n<p style=\"text-align: justify;\">N\u00e1vrat krve z doln\u00edch kon\u010detin zaji\u0161\u0165uje \u017eiln\u011bsvalov\u00e1 pumpa. Pumpov\u00e1n\u00ed krve za\u010d\u00edn\u00e1 v \u017eil\u00e1ch na noze, jejich\u017e obsah je p\u0159i ka\u017ed\u00e9m kroku vytla\u010dov\u00e1n nahoru do oblasti b\u00e9rce a \u017eiln\u00ed tlak v doln\u00ed kon\u010detin\u011b kles\u00e1. Pro spr\u00e1vn\u00e9 fungov\u00e1n\u00ed \u017eiln\u011b-svalov\u00e9 pumpy je pot\u0159ebn\u00e1 sou\u010dinnost kloub\u016f, sval\u016f a \u017eil (\u017eiln\u00ed st\u011bny a \u017eiln\u00edch chlopn\u00ed). U pacient\u016f s poru\u0161enou funkc\u00ed \u017eiln\u011bsvalov\u00e9 pumpy se krev hromad\u00ed v doln\u00edch kon\u010detin\u00e1ch a \u017eiln\u00ed tlak stoup\u00e1. P\u0159i ch\u016fzi vznik\u00e1 ambulantn\u00ed \u017eiln\u00ed hypertenze (ambulantn\u00ed z latinsk\u00e9ho <i>ambulatio<\/i>, f., proch\u00e1zka, proch\u00e1zen\u00ed) s odezvou v makrocirkulaci, mikrocirkulaci a lymfatick\u00fdch c\u00e9v\u00e1ch.<\/p>\n<p style=\"text-align: justify;\">Projevem \u017eiln\u00ed hypertenze v makrocirkulaci doln\u00edch kon\u010detin jsou varixy. Jde o jak\u00e9koliv dilatovan\u00e9, elongovan\u00e9 nebo vinut\u00e9 \u017e\u00edly s nefunk\u010dn\u00edmi chlopn\u011bmi, bez ohledu na jejich velikost. Varix je tedy ko\u017en\u00ed nebo podko\u017en\u00ed \u017e\u00edla, kter\u00e1 definitivn\u011b ztratila funkci sv\u00fdch chlopn\u00ed v d\u016fsledku trval\u00e9 dilatace. Takto posti\u017een\u00e1 \u017e\u00edla se postupn\u011b prodlu\u017euje, st\u00e1\u010d\u00ed a dilatuje, jej\u00ed st\u011bna podl\u00e9h\u00e1 remodelaci.<\/p>\n<p style=\"text-align: justify;\">D\u016fsledkem \u017eiln\u00ed hypertenze v mikrocirkulaci je kapil\u00e1rn\u00ed hypertenze. V kapil\u00e1r\u00e1ch stagnuj\u00ed trombocyty, erytrocyty a leukocyty a ucp\u00e1vaj\u00ed je. P\u0159\u00edsun kysl\u00edku a \u017eivin do tk\u00e1n\u00ed se sni\u017euje. Leukocyty uvol\u0148ov\u00e1n\u00edm kysl\u00edkov\u00fdch radik\u00e1l\u016f a proteolytick\u00fdch enzym\u016f po\u0161kozuj\u00ed tk\u00e1n\u011b, rozv\u00edj\u00ed se steriln\u00ed z\u00e1n\u011bt. Dokud se patologick\u00e9 zm\u011bny t\u00fdkaj\u00ed pouze \u017eil r\u016fzn\u00e9ho kalibru, mluv\u00edme o varixech (st. C1\u2013C2 dle CEAP), lehk\u00e9 form\u011b chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed. Kdy\u017e ale malnutrice a chronick\u00fd steriln\u00ed z\u00e1n\u011bt po\u0161kod\u00ed k\u016f\u017ei a podko\u017e\u00ed, jedn\u00e1 se o chronickou \u017eiln\u00ed insuficienci (st. C4\u2013C6 dle CEAP), pokro\u010dilou formu chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed, kde komplexn\u00ed porucha v\u00fd\u017eivy k\u016f\u017ee a podko\u017e\u00ed usnad\u0148uje rozvoj tk\u00e1\u0148ov\u00e9 nekr\u00f3zy, projevuj\u00edc\u00ed se lipodermatofibr\u00f3zou, \u017eiln\u00edm v\u0159edem a event. i krv\u00e1cen\u00edm (obr. 1).<\/p>\n<h6>KLINICK\u00c9 PROJEVY<\/h6>\n<p style=\"text-align: justify;\">Klasick\u00fdmi viditeln\u00fdmi projevy chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed (\u017eiln\u00ed insuficience) jsou dilatovan\u00e9 intraderm\u00e1rn\u00ed \u017e\u00edly (venektazie), podko\u017en\u00ed \u017e\u00edly (retikul\u00e1rn\u00ed a uzlovit\u00e9 varixy) a r\u016fzn\u011b rozs\u00e1hl\u00e9 otoky. M\u011bkk\u00fd \u017eiln\u00ed otok v m\u00edstech nejvy\u0161\u0161\u00edho hydrostatick\u00e9ho tlaku (nej\u010dast\u011bji jsou to otoky kolem kotn\u00edk\u016f a v dist\u00e1ln\u00ed t\u0159etin\u011b b\u00e9rce) se m\u016f\u017ee objevovat ji\u017e v \u010dasn\u00fdch stadi\u00edch onemocn\u011bn\u00ed v odpoledn\u00edch a ve\u010dern\u00edch hodin\u00e1ch a do r\u00e1na miz\u00ed (ven\u00f3zn\u00ed otok). P\u0159i dlouholet\u00e9m trv\u00e1n\u00ed se \u017eiln\u00ed otok kombinuje s tuh\u00fdm lymfatick\u00fdm otokem (lymfoven\u00f3zn\u00ed otok p\u0159i dynamick\u00e9 lymfatick\u00e9 insuficienci). Na objektivn\u00edch p\u0159\u00edznac\u00edch (symptomatologii) je postaven\u00e9 v praxi b\u011b\u017en\u011b pou\u017e\u00edvan\u00e9 klinick\u00e9 t\u0159\u00edd\u011bn\u00ed \u017eiln\u00ed insuficience v r\u00e1mci CEAP klasifikace (Tab) (Consensus Statement, 1995, Eklof, 2004) (Obr. 2\u20136).<\/p>\n<p style=\"text-align: justify;\">Subjektivn\u00ed pocity t\u00edhy, tlaku, nap\u011bt\u00ed a\u017e bolest\u00ed v DK a no\u010dn\u00ed k\u0159e\u010de v l\u00fdtk\u00e1ch tvo\u0159\u00ed spolu s otoky klasickou tri\u00e1du pot\u00ed\u017e\u00ed spojen\u00fdch s \u017eiln\u00ed insuficienc\u00ed.<\/p>\n<table class=\"CSSTableGenerator\" 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\"><span style=\"color: #ffffff;\">Tabulka \u010d. 1:<\/span><br \/>\n<span style=\"color: #ffffff;\">Klinick\u00e9 t\u0159\u00edd\u011bn\u00ed chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed podle CEAP klasifikace<\/span><br \/>\n<span style=\"color: #ffffff;\">(Consensus statement, 1995)<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C0<\/td>\n<td style=\"border: 1px solid #ffffff; width: 70%; text-align: left;\" align=\"center\" valign=\"top\">\u2013 \u017e\u00e1dn\u00e9 viditeln\u00e9 nebo hmatn\u00e9\u00a0 zn\u00e1mky \u017eiln\u00edho onemocn\u011bn\u00ed<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C1<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 teleangiektazie nebo retikul\u00e1rn\u00ed varixy<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C2<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 uzlovit\u00e9 varixy<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C3<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 otok na doln\u00ed kon\u010detin\u011b<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C4<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 ko\u017en\u00ed zm\u011bny v d\u016fsledku \u017eiln\u00edho\u00a0onemocn\u011bn\u00ed<br \/>\n<em>(nap\u0159. pigmentace, \u017eiln\u00ed ekz\u00e9m, lipodermatoskler\u00f3za)<\/em><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C5<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 ko\u017en\u00ed zm\u011bny jak uvedeno v\u00fd\u0161e s vyhojen\u00fdm v\u0159edem<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">T\u0159\u00edda C6<\/td>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"center\" valign=\"top\">\u2013 ko\u017en\u00ed zm\u011bny jak uvedeno v\u00fd\u0161e s aktivn\u00edm v\u0159edem<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.a<\/span><\/p>\n<p style=\"text-align: justify;\"><em>C = znamen\u00e1 klinick\u00e9 t\u0159\u00edd\u011bn\u00ed chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed v r\u00e1mci CEAP klasifikace p\u0159ijat\u00e9 na 6. v\u00fdro\u010dn\u00ed sch\u016fzi Americk\u00e9ho \u017eiln\u00edho f\u00f3ra (American Venous Forum) 22.\u201325. 2. 1994 v Maui na Havaji. V CEAP klasifikaci jednotliv\u00e1 p\u00edsmena zna\u010d\u00ed: C = klinickou klasifikaci, E = etiologickou klasifikaci (kongenit\u00e1ln\u00ed, prim\u00e1rn\u00ed a sekund\u00e1rn\u00ed \u017eiln\u00ed insuficience), A = anatomickou klasifikaci (p\u0159esn\u00e1 anatomick\u00e1 lokalizace \u017eiln\u00ed insuficience) a P = patofyziologickou klasifikaci \u017eiln\u00ed insuficience (reflux, obstrukce, reflux a obstrukce).<\/em><\/p>\n<h6>DIAGNOSTIKA<\/h6>\n<p style=\"text-align: justify;\">Zhodnotit chronick\u00e9 \u017eiln\u00ed onemocn\u011bn\u00ed doln\u00edch kon\u010detin a odli\u0161it ho od jin\u00fdch nozologick\u00fdch jednotek je mnohem t\u011b\u017e\u0161\u00ed ne\u017e zhodnotit onemocn\u011bn\u00ed tepen. Projevy \u017eiln\u00ed insuficience jsou nespecifick\u00e9, pestr\u00e9 a prom\u011bnliv\u00e9. Nespecifick\u00e9 proto, \u017ee stejn\u00e9 p\u0159\u00edznaky jako u \u017eiln\u00ed insuficience m\u016f\u017eeme pozorovat tak\u00e9 u jin\u00fdch chorob (posti\u017een\u00ed p\u00e1te\u0159e, artr\u00f3za nosn\u00fdch kloub\u016f doln\u00edch kon\u010detin, flebotromb\u00f3za, tromboflebitida). Sv\u00e9 pot\u00ed\u017ee pacienti \u010dasto nep\u0159ipisuj\u00ed zjevn\u00e9mu \u017eiln\u00edmu onemocn\u011bn\u00ed. \u0160irokou \u0161k\u00e1lu stesk\u016f prov\u00e1zej\u00edc\u00edch \u017eiln\u00ed insuficienci lze n\u011bkdy jen s obt\u00ed\u017eemi odli\u0161it od vertebrogenn\u00edch, neuropatick\u00fdch, artrotick\u00fdch a jin\u00fdch skeletomuskul\u00e1rn\u00edch pot\u00ed\u017e\u00ed.<\/p>\n<p style=\"text-align: justify;\">Z\u00e1va\u017enost subjektivn\u00edch pot\u00ed\u017e\u00ed nez\u00e1vis\u00ed na velikosti a rozsahu varix\u016f. \u017dena s drobn\u00fdmi venektaziemi m\u016f\u017ee m\u00edt mnohem v\u011bt\u0161\u00ed obt\u00ed\u017ee ne\u017e mu\u017e s rozs\u00e1hl\u00fdmi uzlovit\u00fdmi varixy na obou stehnech a b\u00e9rc\u00edch.<\/p>\n<p style=\"text-align: justify;\">Pot\u00ed\u017ee spojen\u00e9 s \u017eiln\u00ed insuficienc\u00ed se zhor\u0161uj\u00ed odpoledne a nave\u010der, dlouh\u00fdm st\u00e1n\u00edm a sezen\u00edm, v tepl\u00e9m prost\u0159ed\u00ed, po v\u011bt\u0161\u00ed fyzick\u00e9 n\u00e1maze nebo psychick\u00fdm stresem, na po\u010d\u00e1tku menstruace a v t\u011bhotenstv\u00ed. \u010casto nemocn\u00ed p\u0159ich\u00e1zej\u00ed k l\u00e9ka\u0159i pro v\u00fdrazn\u00e9 no\u010dn\u00ed bolesti a k\u0159e\u010de v doln\u00edch kon\u010detin\u00e1ch, kter\u00e9 jim nedovol\u00ed kvalitn\u00ed sp\u00e1nek. Ke zlep\u0161en\u00ed doch\u00e1z\u00ed zvednut\u00edm doln\u00edch kon\u010detin, pohybem a ve studen\u00e9 vod\u011b.<\/p>\n<p style=\"text-align: justify;\">Diagn\u00f3za chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed jako nozologick\u00e9 jednotky je v\u00fdhradn\u011b klinick\u00e1, vych\u00e1z\u00ed z anamn\u00e9zy a objektivn\u00edho vy\u0161et\u0159en\u00ed. Na z\u00e1klad\u011b anamnestick\u00fdch \u00fadaj\u016f a objektivn\u00edho n\u00e1lezu na doln\u00edch kon\u010detin\u00e1ch m\u016f\u017eeme vyslovit diagn\u00f3zu \u017eiln\u00ed insuficience. Ov\u0161em diagn\u00f3za patofyziologick\u00e1 (p\u0159\u00edtomnost refluxu, obstrukce nebo refluxu a obstrukce) a anatomick\u00e1 (posti\u017een\u00ed povrchov\u00e9ho, hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu, perfor\u00e1tor\u016f) vy\u017eaduje pomocn\u00e1 laboratorn\u00ed vy\u0161et\u0159en\u00ed, v dne\u0161n\u00ed dob\u011b t\u00e9m\u011b\u0159 v\u00fdhradn\u011b ultrazvuk. Ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed tak umo\u017e\u0148uje up\u0159esnit diagn\u00f3zu \u017eiln\u00ed insuficience. Zhodnot\u00ed anatomick\u00fd rozsah a z\u00e1va\u017enost onemocn\u011bn\u00ed a pom\u00e1h\u00e1 l\u00e9ka\u0159i rozhodovat se o zp\u016fsobu l\u00e9\u010dby. Zat\u00edmco v diagnostice \u017eiln\u00ed insuficience si vysta\u010d\u00edme s anamn\u00e9zou a objektivn\u00edm n\u00e1lezem, ka\u017ed\u00fd nemocn\u00fd, u kter\u00e9ho pl\u00e1nujeme opera\u010dn\u00ed l\u00e9\u010dbu, v\u010detn\u011b sklerotizace, mus\u00ed m\u00edt p\u0159edt\u00edm ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed \u017eiln\u00edho syst\u00e9mu doln\u00edch kon\u010detin.<\/p>\n<p style=\"text-align: justify;\">C\u00edlem l\u00e9\u010dby \u017eiln\u00ed insuficience je eliminovat nebo alespo\u0148 sn\u00ed\u017eit ambulantn\u00ed \u017eiln\u00ed hypertenzi. <b>Konzervativn\u00ed <\/b>l\u00e9\u010dbou jsou re\u017eimov\u00e1 a dietn\u00ed opat\u0159en\u00ed, elevace a komprese doln\u00edch kon\u010detin, celkov\u00e1 a lok\u00e1ln\u00ed farmakoterapie. U ob\u00e9zn\u00edch pacient\u016f nesm\u00edme zapomenout na redukci t\u011blesn\u00e9 hmotnosti. Tyto postupy v\u0161ak ne\u0159e\u0161\u00ed kauz\u00e1ln\u00ed hemodynamickou poruchu, tedy reflux a\/nebo obstrukci v \u017eiln\u00edm syst\u00e9mu. Reflux v hlavn\u00edch refluxn\u00edch m\u00edstech (safenofemor\u00e1ln\u00ed a safenopoplite\u00e1ln\u00ed junkce) povrchov\u00e9ho \u017eiln\u00edho syst\u00e9mu je mo\u017en\u00e9 zru\u0161it pouze l\u00e9\u010dbou <b>chirurgickou <\/b>(klasick\u00e1 chirurgick\u00e1 a endoskopick\u00e1 l\u00e9\u010dba, endoven\u00f3zn\u00ed laserov\u00e1 nebo radiofrekven\u010dn\u00ed obliterace), u drobn\u011bj\u0161\u00edch, nekmenov\u00fdch varix\u016f lze pou\u017e\u00edt <b>kompresivn\u00ed skleroterapii.<\/b><\/p>\n<p style=\"text-align: justify;\">Kompresivn\u00ed terapie je z\u00e1kladem l\u00e9\u010dby v\u0161ech klinick\u00fdch t\u0159\u00edd chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed. Jde o tlak aplikovan\u00fd na kon\u010detinu pomoc\u00ed kr\u00e1tkota\u017en\u00e9 \u010di dlouhota\u017en\u00e9 band\u00e1\u017ee, elastick\u00e9 nebo neelastick\u00e9 pun\u010dochy. \u00da\u010dinnost spr\u00e1vn\u011b zalo\u017een\u00e9 band\u00e1\u017ee nebo kompresivn\u00ed pun\u010dochy je p\u0159itom srovnateln\u00e1 (\u0160vestkov\u00e1, 1996). Sebel\u00e9pe nalo\u017een\u00e1 band\u00e1\u017e ale rychle povol\u00ed a je probl\u00e9m ji spr\u00e1vn\u011b nalo\u017eit, proto v kompresivn\u00ed terapii d\u00e1v\u00e1me p\u0159ednost kompresivn\u00edm pun\u010doch\u00e1m.<\/p>\n<p style=\"text-align: justify;\"><strong>Venofarmaka<\/strong> p\u0159edstavuj\u00ed symptomatickou l\u00e9\u010dbu. Od venofarmaka nelze o\u010dek\u00e1vat vymizen\u00ed varix\u016f, prevenci vzniku varix\u016f nebo flebotromb\u00f3zy, ale symptomatickou \u00falevu a potla\u010den\u00ed otok\u016f. Na venofarmaka bylo dlouho nahl\u00ed\u017eeno s ur\u010dit\u00fdm despektem. V posledn\u00edch letech v\u0161ak byla tato l\u00e9\u010diva podrobena kontrolovan\u00fdm klinick\u00fdm studi\u00edm, kter\u00e9 jejich \u00fa\u010dinnost potvrdily (Norgen, 1997).<\/p>\n<p style=\"text-align: justify;\">K nejroz\u0161\u00ed\u0159en\u011bj\u0161\u00edm venofarmak\u016fm pat\u0159\u00ed p\u0159\u00edrodn\u00ed flavonoidy (mikronizovan\u00e1, purifikovan\u00e1 flavonoidn\u00ed frakce), rutin, oxerutin a troxerutin, kter\u00e9 maj\u00ed p\u0159i celkov\u00e9m pod\u00e1v\u00e1n\u00ed minimum ne\u017e\u00e1douc\u00edch \u00fa\u010dink\u016f, objevuj\u00edc\u00edch se u m\u00e9n\u011b ne\u017e 10% l\u00e9\u010den\u00fdch. Jde hlavn\u011b o nauzeu, ko\u017en\u00ed alergick\u00e9 projevy a bolesti b\u0159icha. Venofarmaka zlep\u0161uj\u00ed \u017eiln\u00ed a lymfatick\u00fd n\u00e1vrat, redukuj\u00ed t\u00edm \u017eiln\u00ed hypertenzi a maj\u00ed tak pozitivn\u00ed vliv na pr\u016ftok krve mikrocirkulac\u00ed, sni\u017euj\u00ed viskozitu krve, agregabilitu erytrocyt\u016f, adhezi leukocyt\u016f k c\u00e9vn\u00edmu endotelu, sni\u017euj\u00ed propustnost kapil\u00e1r, zvy\u0161uj\u00ed fibrinolytickou aktivitu krve a maj\u00ed membr\u00e1no-protektivn\u00ed p\u016fsoben\u00ed.<\/p>\n<p style=\"text-align: justify;\"><strong>Doba l\u00e9\u010den\u00ed venofarmaky<\/strong> nen\u00ed p\u0159esn\u011b stanovena. \u00davodn\u00ed pod\u00e1v\u00e1n\u00ed jak\u00e9hokoliv venofarmaka by m\u011blo tr vat alespo\u0148 6\u20138 t\u00fddn\u016f. N\u011bkdy je u nemocn\u00fdch vhodn\u00e9 dlouhodob\u00e9 intermitentn\u00ed pod\u00e1v\u00e1n\u00ed, tedy 4\u20136 t\u00fddn\u016f venofarmaka pod\u00e1vat a stejnou dobu je vynechat, jindy je vhodn\u011bj\u0161\u00ed del\u0161\u00ed kontinu\u00e1ln\u00ed pod\u00e1v\u00e1n\u00ed, zejm\u00e9na v letn\u00edch m\u011bs\u00edc\u00edch. Trv\u00e1n\u00ed l\u00e9\u010dby by m\u011blo b\u00fdt ponech\u00e1no na \u00favaze o\u0161et\u0159uj\u00edc\u00edho l\u00e9ka\u0159e.<\/p>\n<p style=\"text-align: justify;\">Zat\u00edm neexistuje v\u011bdeck\u00fd d\u016fkaz o \u00fa\u010dinnosti l\u00e9k\u016f a komprese na teleangiektazie a retikul\u00e1rn\u00ed varixy. Pokud neprok\u00e1\u017eeme reflux v hlavn\u00edch kmenech povrchov\u00fdch \u017eil, je v t\u011bchto p\u0159\u00edpadech mo\u017eno doporu\u010dit <b>kompresivn\u00ed skleroterapii<\/b>. Jde o injek\u010dn\u00ed aplikaci chemick\u00fdch l\u00e1tek navozuj\u00edc\u00edch fibrotizaci \u017eiln\u00ed st\u011bny s n\u00e1sledn\u00fdm uz\u00e1v\u011brem varix\u016f. Nov\u011bji se pou\u017e\u00edv\u00e1 ultrazvukem kontrolovan\u00e1 skleroterapie (ultrasoundguided sclerotherapy, UGS). \u00da\u010dinnost t\u00e9to l\u00e9\u010dby je asi 80%, ale \u010d\u00e1st \u017eil se \u010dasem op\u011bt rekanalizuje. Skleroterapie je adekv\u00e1tn\u00ed l\u00e9\u010dbou nekmenov\u00fdch varix\u016f\u2013 rezidu\u00e1ln\u00edch varix\u016f po operaci, lok\u00e1ln\u00edch varix\u016f a varik\u00f3zn\u00edch p\u0159\u00edtok\u016f do kmene zat\u00edm dob\u0159e funk\u010dn\u00ed velk\u00e9 nebo mal\u00e9 safeny. Kr\u00e1tkodob\u00e9 v\u00fdsledky t\u00e9to l\u00e9\u010dby jsou dobr\u00e9, zat\u00edm ale chyb\u00ed studie k posouzen\u00ed dlouhodob\u00fdch v\u00fdsledk\u016f.U rozs\u00e1hl\u00fdch uzlovit\u00fdch varix\u016f by m\u011bla b\u00fdt l\u00e9\u010dbou prvn\u00ed volby klasick\u00e1 chirurgick\u00e1 intervence formou <b>ligace a stripingu kmene safeny<\/b>. Odstran\u011bn\u00ed safeny (striping) je bu\u010f tot\u00e1ln\u00ed, v cel\u00e9m jej\u00edm pr\u016fb\u011bhu na doln\u00ed kon\u010detin\u011b od t\u0159\u00edsla po vnit\u0159n\u00ed kotn\u00edk nebo subtot\u00e1ln\u00ed, tj. odstran\u011bn\u00ed \u017e\u00edly pouze na stehn\u011b. Mezi nov\u011bj\u0161\u00ed radik\u00e1ln\u00ed l\u00e9\u010debn\u00e9 metody \u0159ad\u00edme <b>laserovou a radiofrekven\u010dn\u00ed endoven\u00f3zn\u00ed obliteraci varix\u016f<\/b>.<\/p>\n<p style=\"text-align: justify;\"><strong>\u017diln\u00ed b\u00e9rcov\u00fd v\u0159ed p\u0159edstavuje tvrd\u00fd terapeutick\u00fd o\u0159\u00ed\u0161ek<\/strong>. Ulcerace nevykazuj\u00edc\u00ed ani po t\u0159ech m\u011bs\u00edc\u00edch intenzivn\u00ed l\u00e9\u010dby tendenci k hojen\u00ed naz\u00fdv\u00e1me rezistentn\u00ed v\u016f\u010di terapii (cca 20% v\u0159ed\u016f). Spektrum l\u00e9\u010dby \u017eiln\u00edch b\u00e9rcov\u00fdch v\u0159ed\u016f zahrnuje fyzioterapii, kompresivn\u00ed l\u00e9\u010dbu, chirurgickou l\u00e9\u010dbu, lok\u00e1ln\u00ed a celkovou farmakoterapii, <strong>p\u0159i\u010dem\u017e je d\u016fraz kladen\u00fd na lok\u00e1ln\u00ed a kompresivn\u00ed l\u00e9\u010dbu dopln\u011bnou re\u017eimov\u00fdmi opat\u0159en\u00edmi<\/strong>.<\/p>\n<p style=\"text-align: justify;\"><strong>Fyzioterapie<\/strong> p\u0159edstavuje intenzivn\u00ed tr\u00e9nink ch\u016fz\u00ed, zlep\u0161ov\u00e1n\u00ed pohyblivosti kloub\u016f, zvl\u00e1\u0161t\u011b talokrur\u00e1ln\u00edho, polohov\u00e1n\u00ed doln\u00edch kon\u010detin (co nej\u010dast\u011bj\u0161\u00ed elevace), manu\u00e1ln\u00ed lymfatickou dren\u00e1\u017e a intermitentn\u00ed pneumatickou kompresi.<\/p>\n<p style=\"text-align: justify;\"><strong>Z\u00e1kladn\u00edm kamenem l\u00e9\u010dby b\u00e9rcov\u00fdch v\u0159ed\u016f \u017eiln\u00edho p\u016fvodu je \u00fa\u010dinn\u00e1 kompresivn\u00ed terapie (tlak nad kotn\u00edkem alespo\u0148 35 mm Hg).<\/strong> P\u0159ednost se d\u00e1v\u00e1 m\u00edrn\u011b elastick\u00fdm obvaz\u016fm. Lok\u00e1ln\u00ed tlak na oblast v\u0159edu se zvy\u0161uje pomoc\u00ed podlo\u017eek. Ty jsou zvl\u00e1\u0161t\u011b d\u016fle\u017eit\u00e9 pro v\u0159edy v retromaleol\u00e1rn\u00ed jamce. Kontraindikac\u00ed komprese je tepenn\u00e1 obliteruj\u00edc\u00ed nemoc s tlakem v \u00farovn\u00ed kotn\u00edku 60\u201380 mm Hg.<\/p>\n<p style=\"text-align: justify;\"><strong>Lok\u00e1ln\u00ed terapie<\/strong> m\u00e1 za c\u00edl podpo\u0159it hojen\u00ed. Nekrotick\u00e1 tk\u00e1\u0148 mus\u00ed b\u00fdt v\u017edy odstran\u011bna. K vy\u010di\u0161t\u011bn\u00ed v\u0159ed\u016f se doporu\u010duje steriln\u00ed fyziologick\u00fd roztok. Zat\u00edm nebylo prok\u00e1z\u00e1no, \u017ee by n\u011bjak\u00fd druh bakteri\u00ed, kontaminuj\u00edc\u00edch v\u0159ed, ovlivnil diagnostiku, terapii nebo progn\u00f3zu floridn\u00edho \u017eiln\u00edho b\u00e9rcov\u00e9ho v\u0159edu. V kontrolovan\u00fdch studi\u00edch se v\u0159edy l\u00e9\u010den\u00e9 antibiotiky hojily stejn\u011b rychle jako v\u0159edy l\u00e9\u010den\u00e9 pouze \u00fa\u010dinnou kompres\u00ed. Syst\u00e9mov\u00e1 farmakoterapie (aspirin, pentoxyphyllin, prostaglandiny, flavonoidy atd.) zat\u00edm sehr\u00e1v\u00e1 pouze pomocnou \u00falohu.<\/p>\n<p><!--nextpage--><\/p>\n<h3>10.2 Akutn\u00ed \u017eiln\u00ed onemocn\u011bn\u00ed<\/h3>\n<h4>10.2.1 Tromboflebitida<\/h4>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o z\u00e1n\u011bt k\u016f\u017ee a podko\u017e\u00ed spojen\u00fd s posti\u017een\u00edm povrchov\u00e9 \u017e\u00edly, ve kter\u00e9 vznik\u00e1 tromb\u00f3za. V n\u011bkter\u00fdch p\u0159\u00edpadech dominuje sp\u00ed\u0161e z\u00e1n\u011bt, v jin\u00fdch tromb\u00f3za. Afekce b\u00fdv\u00e1 bolestiv\u00e1. Jako Mondorovu flebitidu ozna\u010dujeme izolovanou flebitidu s fibroprodukc\u00ed, kdy na hrudn\u00edku nach\u00e1z\u00edme v\u00fdrazn\u011b tuh\u00e9 \u017e\u00edly bez typick\u00fdch zn\u00e1mek z\u00e1n\u011btu v okol\u00ed. Na vzniku tromboflebitidy se r\u016fznou m\u011brou pod\u00edl\u00ed porucha hemost\u00e1zy, z\u00e1n\u011bt a poruchy krevn\u00edho toku. Tromboflebitida se m\u016f\u017ee objevit na kter\u00e9koliv \u010d\u00e1sti t\u011bla, ale nej\u010dast\u011bji vznik\u00e1 na doln\u00edch kon\u010detin\u00e1ch, kde postihuje varik\u00f3zn\u00ed \u017e\u00edly.Podle lokalizace a etiopatogenze rozli\u0161ujeme na doln\u00edch kon\u010detin\u00e1ch t\u0159i z\u00e1kladn\u00ed klinick\u00e9 varianty tromboflebitidy:<\/p>\n<ol>\n<li style=\"text-align: justify;\"><b>Tromboflebitis vulgaris superficialis \u2013 prim\u00e1rn\u00ed povrchov\u00e1 tromboflebitida\/flebitida <\/b>(z\u00e1n\u011bt dosud zdrav\u00e9 podko\u017en\u00ed \u017e\u00edly). M\u016f\u017ee se jednat o idiopatick\u00e9 onemocn\u011bn\u00ed, ale z\u00e1n\u011bt p\u0159edt\u00edm zdrav\u00e9 \u017e\u00edly se n\u011bkdy objevuje v r\u00e1mci celkov\u00e9ho onemocn\u011bn\u00ed, nap\u0159. p\u0159i malignit\u011b, kortikoterapii u mlad\u00fdch \u017een, p\u0159i trombofilii, sepsi \u010di bakteri\u00e9mii. Tromboflebitida tak \u010dasto b\u00fdv\u00e1 prvn\u00edm varovn\u00fdm znamen\u00edm doposud nerozpoznan\u00e9 malignity.<\/li>\n<li style=\"text-align: justify;\">Do t\u00e9to skupiny pat\u0159\u00ed iatrogenn\u011b navozen\u00e1 <b>infuzn\u00ed flebitida<\/b>, steriln\u00ed z\u00e1n\u011bt \u017eiln\u00ed st\u011bny u pacient\u016f s dlouhodob\u011b zaveden\u00fdm intraven\u00f3zn\u00edm kat\u00e9trem, ale i po opakovan\u00fdch \u017eiln\u00edch odb\u011brech. Tromb\u00f3za vznik\u00e1 mechanick\u00fdm dr\u00e1\u017ed\u011bn\u00edm \u017eiln\u00ed st\u011bny nebo chemick\u00fdm a osmotick\u00fdm p\u016fsoben\u00edm intraven\u00f3zn\u011b aplikovan\u00e9 l\u00e1tky. Infuzn\u00ed flebitidy se n\u011bkdy mohou komplikovat hlubokou \u017eiln\u00ed tromb\u00f3zou. Za nep\u0159\u00edzniv\u00fdch prokoagula\u010dn\u00edch podm\u00ednek se m\u016f\u017ee rozvinout a\u017e hlubok\u00e1 tromb\u00f3za brachi\u00e1ln\u00ed, axill\u00e1rn\u00ed a podkl\u00ed\u010dkov\u00e9 \u017e\u00edly.<\/li>\n<li style=\"text-align: justify;\">P\u0159i bakteri\u00e1ln\u00ed infekci mluv\u00edme o tzv. <b>infek\u010dn\u00ed (septick\u00e9) flebitid\u011b<\/b>. V\u011bt\u0161inou se jedn\u00e1 o streptokokov\u00e9 a stafylokokov\u00e9 infekce.<\/li>\n<li style=\"text-align: justify;\"><b>Varikoflebitida <\/b>(z\u00e1n\u011bt varix\u016f \u2013 nej\u010dast\u011bj\u0161\u00ed varianta, asi desetkr\u00e1t \u010dast\u011bj\u0161\u00ed ne\u017e prim\u00e1rn\u00ed tromboflebitida). Je typickou komplikac\u00ed varix\u016f doln\u00edch kon\u010detin. Nej\u010dast\u011bji je lokalizov\u00e1na v pr\u016fb\u011bhu varik\u00f3zn\u011b zm\u011bn\u011bn\u00e9ho kmene velk\u00e9 a mal\u00e9 safeny. Ve varik\u00f3zn\u011b zm\u011bn\u011bn\u00e9 \u017e\u00edle doch\u00e1z\u00ed ke stagnaci krve, m\u011bn\u00ed se chov\u00e1n\u00ed bun\u011b\u010dn\u00fdch slo\u017eek krve, endotelu a lok\u00e1ln\u011b se tak zvy\u0161uje krevn\u00ed sr\u00e1\u017elivost. N\u00e1sledn\u011b sta\u010d\u00ed men\u0161\u00ed vyvol\u00e1vaj\u00edc\u00ed podn\u011bt, jako je nap\u0159\u00edklad drobn\u00e9 poran\u011bn\u00ed v m\u00edst\u011b varix\u016f, vytvo\u0159\u00ed se z\u00e1n\u011bt \u017eiln\u00ed st\u011bny a dojde k odstartov\u00e1n\u00ed koagula\u010dn\u00ed kask\u00e1dy s vytvo\u0159en\u00edm velik\u00e9ho nitro\u017eiln\u00edho trombu nasedaj\u00edc\u00edho na po\u0161kozenou \u017eiln\u00ed st\u011bnu.<\/li>\n<li style=\"text-align: justify;\"><b>Tromboflebitis saltans seu migrans <\/b>(migruj\u00edc\u00ed z\u00e1n\u011bt podko\u017en\u00edch \u017eil). Jedn\u00e1 se o z\u00e1n\u011bty krat\u0161\u00edch \u00fasek\u016f \u017eil, v atypick\u00fdch lokalizac\u00edch, kter\u00e9 se st\u011bhuj\u00ed z m\u00edsta na m\u00edsto, p\u0159\u00edpadn\u011b se \u0161\u00ed\u0159\u00ed proxim\u00e1ln\u011b nebo dist\u00e1ln\u011b a mohou postihovat v\u00edce m\u00edst sou\u010dasn\u011b na n\u011bkolika kon\u010detin\u00e1ch. M\u016f\u017ee b\u00fdt sou\u010d\u00e1st\u00ed z\u00e1va\u017en\u00e9ho onemocn\u011bn\u00ed: n\u00e1dor, TBC, obliteruj\u00edc\u00ed trombangiitida (Buergerova nemoc), vaskulitidy, kolagen\u00f3zy. Etiologie zat\u00edm nen\u00ed jasn\u00e1. Speci\u00e1ln\u00edm typem migruj\u00edc\u00ed tromboflebitidy je <b>Mondorova choroba<\/b>. Jedn\u00e1 se o vz\u00e1cnou, idiopatickou, spont\u00e1nn\u011b ustupuj\u00edc\u00ed tromboflebitidu p\u0159edt\u00edm zdrav\u00fdch \u017eil na p\u0159edn\u00ed a bo\u010dn\u00ed stran\u011b hrudn\u00edku a b\u0159icha a jejich p\u0159em\u011bnu ve vazivov\u00e9 pruhy. Trv\u00e1-li tromboflebitida d\u00e9le ne\u017e 30 dn\u00ed, mluv\u00edme o <b>chronick\u00e9 tromboflebitid\u011b<\/b>. V 60\u201380% tromboflebitida postihuje velkou safenu a jej\u00ed p\u0159\u00edtoky. Z\u00e1va\u017enou komplikac\u00ed je flebotromb\u00f3za, a\u0165 ji\u017e spojit\u00e1 (trombus se z povrchov\u00fdch \u017eil kontinu\u00e1ln\u011b \u0161\u00ed\u0159\u00ed safenofemor\u00e1ln\u00ed, safenopoplite\u00e1ln\u00ed junkc\u00ed nebo perfor\u00e1tory do hlubok\u00fdch \u017eil) nebo nespojit\u00e1 (izolovan\u00e1 tromboflebitida prov\u00e1zen\u00e1 izolovanou flebotromb\u00f3zou). Mohou nastat i komplikace septick\u00e9 a recidiva.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Pro diagnostiku m\u00e1 v\u00fdznam anamn\u00e9za, klinick\u00e9 a ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed. Klinick\u00fd obraz je charakteristick\u00fd lok\u00e1ln\u00ed bolestivost\u00ed, citlivost\u00ed, zarudnut\u00edm a otokem v pr\u016fb\u011bhu posti\u017een\u00e9 \u017e\u00edly. N\u011bkdy je zv\u00fd\u0161en\u00e1 teplota, u infek\u010dn\u00edch tromboflebitid hore\u010dka.Dopl\u0148uj\u00edc\u00edm vy\u0161et\u0159en\u00edm by m\u011blo b\u00fdt p\u00e1tr\u00e1n\u00ed po vyvol\u00e1vaj\u00edc\u00ed p\u0159\u00ed\u010din\u011b prim\u00e1rn\u00ed tromboflebitidy (screening malignity a vaskulitidy). Po vyvol\u00e1vaj\u00edc\u00ed p\u0159\u00ed\u010din\u011b tromboflebitidy bychom m\u011bli p\u00e1trat zejm\u00e9na p\u0159i recidivuj\u00edc\u00ed a\/nebo multifok\u00e1ln\u00ed prim\u00e1rn\u00ed tromboflebitid\u011b a p\u0159i sou\u010dasn\u00e9m v\u00fdskytu nespojit\u00e9 rozs\u00e1hl\u00e9 flebotromb\u00f3zy.<\/p>\n<h6>TERAPIE TROMBOFLEBITIDY<\/h6>\n<ul>\n<li>konzervativn\u00ed (kompresivn\u00ed, lok\u00e1ln\u00ed a celkov\u00e1 farmakoterapie),<\/li>\n<li>chirurgick\u00e1.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Tromboflebitida je v\u011bt\u0161inou \u0159e\u0161ena konzervativn\u011b. Kompresivn\u00ed l\u00e9\u010dba spolu s lok\u00e1ln\u00ed farmakoterapi\u00ed (masti, gely) p\u0159in\u00e1\u0161ej\u00ed v\u011bt\u0161inou rychlou \u00falevuod subjektivn\u00edch pot\u00ed\u017e\u00ed. Lok\u00e1ln\u00ed l\u00e9\u010dba neovliv\u0148uje ascendentn\u00ed progresi tromboflebitidy a vznik tromboembolick\u00e9 choroby. Celkov\u00e1 farmakoterapie je spolu s pevnou kompres\u00ed a ch\u016fz\u00ed z\u00e1kladem konzervativn\u00ed l\u00e9\u010dby. Hepariny a nesteroidn\u00ed antiflogistika dnes p\u0159edstavuj\u00ed nej\u00fa\u010dinn\u011bj\u0161\u00ed farmakoterapii.<\/p>\n<p style=\"text-align: justify;\">U pacient\u016f nereaguj\u00edc\u00edch na konzervativn\u00ed l\u00e9\u010dbu se prov\u00e1d\u00ed chirurgick\u00e1 intervence (flebotomie \u2013 incizea vym\u00e1\u010dknut\u00ed trombu, p\u0159eru\u0161en\u00ed safenofemor\u00e1ln\u00ed\/safenopoplite\u00e1ln\u00ed junkce, striping safeny) Chirurgick\u00fdm p\u0159eru\u0161en\u00edm junkce safen lze doplnit heparinizaci p\u0159i ascendentn\u00edm \u0161\u00ed\u0159en\u00ed tromboflebitidy.<\/p>\n<h4>10.2.2 Flebotromb\u00f3za<\/h4>\n<p style=\"text-align: justify;\">Krevn\u00ed sra\u017eenina, trombus, m\u016f\u017ee vzniknout kdekoliv v c\u00e9vn\u00edm \u0159e\u010di\u0161ti, v \u017eil\u00e1ch, tepn\u00e1ch nebo v mikrocirkulaci. Trombus je slo\u017een\u00fd z krevn\u00edch bun\u011bk, erytrocyt\u016f, trombocyt\u016f a leukocyt\u016f, spojen\u00fdch fibrinem v jeden celek. Vz\u00e1jemn\u00fd pom\u011br mezi fibrinem a bu\u0148kami z\u00e1vis\u00ed zejm\u00e9na na hemodynamick\u00fdch faktorech, p\u0159i kter\u00fdch se trombus tvo\u0159\u00ed.<\/p>\n<p style=\"text-align: justify;\"><strong>Arteri\u00e1ln\u00ed tromby<\/strong> vznikaj\u00ed v rychle proud\u00edc\u00ed krvi, proto jsou tvo\u0159eny hlavn\u011b desti\u010dkov\u00fdmi agreg\u00e1ty, spojen\u00fdmi tenk\u00fdmi a dlouh\u00fdmi vl\u00e1kny fibrinu. Mluv\u00edme o desti\u010dkov\u00e9m, b\u00edl\u00e9m trombu. Naproti tomu <strong>\u017eiln\u00ed tromby<\/strong> vznikaj\u00ed v stagnuj\u00edc\u00ed krvi a jsou slo\u017eeny p\u0159ev\u00e1\u017en\u011b z erytrocyt\u016f a velk\u00e9ho mno\u017estv\u00ed tlust\u00fdch vl\u00e1ken fibrinu. Trombocyt\u016f je v tomto stagna\u010dn\u00edm \u010derven\u00e9m trombu m\u00e1lo. V pomal\u00e9m krevn\u00edm proud\u011bn\u00ed se objevuj\u00ed sm\u00ed\u0161en\u00e9, desti\u010dko-erytrocyto-fibrinov\u00e9 tromby.<\/p>\n<p style=\"text-align: justify;\">Ji\u017e v 19. stolet\u00ed definoval Virchow t\u0159i z\u00e1kladn\u00ed etiologick\u00e9 faktory flebotromb\u00f3zy \u2013 <strong>po\u0161kozen\u00ed c\u00e9vn\u00ed st\u011bny, m\u011bstn\u00e1n\u00ed krve a \u201ezm\u011bny ve slo\u017een\u00ed krve\u201c (hyperkoagulabilita \u2013 hyperkoagula\u010dn\u00ed stav).<\/strong><\/p>\n<p style=\"text-align: justify;\">Ro\u010dn\u00ed incidence tromboembolick\u00e9 nemoci (TEN), tedy hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy a plicn\u00ed embolie, je u b\u00edl\u00e9 populace asi 0,1\u20130,2%. P\u0159ed 20. rokem \u017eivota se TEN vyskytuje velmi vz\u00e1cn\u011b, ale po 45. roce \u017eivota ro\u010dn\u00ed incidence rychle stoup\u00e1, v ka\u017ed\u00e9 dek\u00e1d\u011b se p\u0159ibli\u017en\u011b zdvojn\u00e1sobuje. Ve v\u011bku nad 75 let TEN postihuje 1% populace (1 p\u0159\u00edpad na 100 obyvatel za rok).<\/p>\n<h6>RIZIKOV\u00c9 FAKTORY<\/h6>\n<ol>\n<li style=\"text-align: justify;\"><strong>V\u011bk nad 45 let<\/strong>, vy\u0161\u0161\u00ed rizikovou kategorii p\u0159edstavuje v\u011bk nad 75 let.<\/li>\n<li style=\"text-align: justify;\"><strong>Zevn\u00ed rizikov\u00e9 faktory<\/strong>: operace (zejm\u00e9na ortopedick\u00e9, traumatologick\u00e9, neurochirurgick\u00e9 a operace pro n\u00e1dor), hospitalizace, imobilizace, trauma, t\u011bhotenstv\u00ed, \u0161estined\u011bl\u00ed, hormon\u00e1ln\u00ed antikoncepce a substituce, chemo\/radioterapie, centr\u00e1ln\u00ed \u017eiln\u00ed kat\u00e9tr.<\/li>\n<li style=\"text-align: justify;\"><b>Vnit\u0159n\u00ed rizikov\u00e9 faktory<\/b>: obezita, aktivn\u00ed n\u00e1dor, z\u00e1n\u011btliv\u00e1 onemocn\u011bn\u00ed, chronick\u00e9 srde\u010dn\u00ed a plicn\u00ed selh\u00e1n\u00ed, nefrotick\u00fd syndrom, <i>polycytemia vera<\/i>, z\u00edskan\u00e9 a vrozen\u00e9 poruchy koagulace (APC rezistence, mutace protrombinu, deficit proteinu, C, S a antitrombinu III) (Musil, 2009).Klinick\u00e9 p\u0159\u00edznaky hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy vznikaj\u00ed obstrukc\u00ed odtoku \u017eiln\u00ed krve, z\u00e1n\u011btem \u017eiln\u00ed st\u011bny a perivaskul\u00e1rn\u00ed tk\u00e1n\u011b. Tromb\u00f3za postihuje hlavn\u011b \u017e\u00edly p\u00e1nve a doln\u00edch kon\u010detin. Trombus se za\u010d\u00edn\u00e1 formovat v sinusech chlopn\u00ed svalov\u00fdch \u017eil l\u00fdtka a b\u00e9rcov\u00fdch \u017eil (<i>vv. tibiales ant. et post.<\/i>). V\u011bt\u0161inou se zde po ur\u010dit\u00e9 dob\u011b spont\u00e1nn\u011b rozpust\u00ed (cca 40%) nebo organizuje bez dal\u0161\u00ed progrese (cca 40%). Asi ve 20% p\u0159\u00edpad\u016f se nel\u00e9\u010den\u00e1 b\u00e9rcov\u00e1 flebotromb\u00f3za \u0161\u00ed\u0159\u00ed proxim\u00e1ln\u011b do podkolenn\u00ed \u017e\u00edly a \u017eil stehna a p\u00e1nve. D\u011bje se tak b\u011bhem jednoho t\u00fddne od za\u010d\u00e1tku onemocn\u011bn\u00ed. U proxim\u00e1ln\u00ed flebotromb\u00f3zy hroz\u00ed p\u0159ibli\u017en\u011b v 50% p\u0159\u00edpad\u016f symptomatick\u00e1 nebo asymptomatick\u00e1 plicn\u00ed embolie (Bates, 2004).<\/li>\n<\/ol>\n<h6>DIAGNOSTIKA<\/h6>\n<p style=\"text-align: justify;\">Spolehliv\u00e1 diagnostika onemocn\u011bn\u00ed pouze na z\u00e1klad\u011b anamn\u00e9zy a fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed je velmi nespolehliv\u00e1, pokud odhl\u00e9dneme od evidentn\u00edch klinick\u00fdch obraz\u016f spojen\u00fdch s phlegmasia dolens. V\u017edy se mus\u00edme op\u0159\u00edt o pomocn\u00e1 laboratorn\u00ed vy\u0161et\u0159en\u00ed.<\/p>\n<p style=\"text-align: justify;\">Od poloviny 80. let 20. stolet\u00ed se v diagnostice flebotromb\u00f3zy za\u010dala pou\u017e\u00edvat ultrasonografie (tzv. kompresn\u00ed ultrazvukov\u00e1 metoda). Postupn\u011b se z n\u00ed stal nov\u00fd diagnostick\u00fd standard vytla\u010duj\u00edc\u00ed z tohoto postu rentgenovou flebografii. Pouze pro zobrazen\u00ed uz\u00e1v\u011bru \u017eil p\u00e1nve je vhodn\u011bj\u0161\u00ed transfemor\u00e1ln\u00ed ascendentn\u00ed flebografie nebo MR. Ultrasonografie m\u00e1 vysokou senzitivitu a specificitu. Dal\u0161\u00edmi p\u0159ednostmi t\u00e9to metody jsou n\u00edzk\u00e1 cena, \u0161etrnost, dostupnost a opakovatelnost. Dnes je pro diagnostiku flebotromb\u00f3zy doln\u00edch kon\u010detin dostate\u010dn\u011b senzitivn\u00ed a specifick\u00e1 kombinace klinick\u00e9ho hodnocen\u00ed s kompresn\u00ed ultrasonografi\u00ed a vy\u0161et\u0159en\u00edm D-dim\u00e9r\u016f. U pacient\u016f s flebotromb\u00f3zou je v\u017edy nutn\u00e9 p\u00e1trat po klinick\u00fdch p\u0159\u00edznac\u00edch plicn\u00ed embolie (du\u0161nost, ka\u0161el, bolesti na hrudn\u00edku, synkopa, tachykardie).<\/p>\n<p style=\"text-align: justify;\">V diferenci\u00e1ln\u00ed diagnostice mus\u00edme m\u00edt na mysli \u0159adu onemocn\u011bn\u00ed svalov\u00fdch, kloubn\u00edch, kostn\u00edch, vertebrogenn\u00edch a nervov\u00fdch (onemocn\u011bn\u00ed bedern\u00ed p\u00e1te\u0159e s ko\u0159enovou iradiac\u00ed do jedn\u00e9 doln\u00ed kon\u010detiny, artrotick\u00e9 pot\u00ed\u017ee \u2013 koxartr\u00f3za, gonartr\u00f3za, bolestiv\u00e1 lipodystrofie, diabetick\u00e1 perifern\u00ed polyneuropatie, kloubn\u00ed a svalov\u00fd revmatismus, neuropatie \u2013 etylick\u00e1, diabetick\u00e1, metabolick\u00e1, n\u00e1dorov\u00e1, posttraumatick\u00e1, traumatick\u00e1 posti\u017een\u00ed \u2013 ruptura svalu nebo ligamenta, kontuze, podvrtnut\u00ed, podko\u017en\u00ed cysty a n\u00e1dory, podko\u017en\u00ed nebo svalov\u00e9 hematomy. U v\u0161ech pacient\u016f s tromboflebitidou (tromb\u00f3za povrchov\u00fdch \u017eil, nej\u010dast\u011bji velk\u00e9 safeny a jej\u00edch v\u011btv\u00ed) mus\u00edme sonograficky vylou\u010dit tromb\u00f3zu hlubok\u00fdch \u017eil! D\u016fvodem je vysok\u00e1 koincidence t\u011bchto dvou onemocn\u011bn\u00ed (pr\u016fm\u011brn\u011b kolem 30%).<\/p>\n<h6>L\u00c9\u010cBA<\/h6>\n<p>\u2022 Terapie TEN m\u00e1 dva c\u00edle:<\/p>\n<ol>\n<li style=\"text-align: justify;\">kr\u00e1tkodob\u00e9 \u2013 \u00faleva od subjektivn\u00edch pot\u00ed\u017e\u00ed, prevence proxim\u00e1ln\u00edho \u0161\u00ed\u0159en\u00ed tromb\u00f3zy, prevenceplicn\u00ed embolie,<\/li>\n<li style=\"text-align: justify;\">dlouhodob\u00e9 \u2013 prevence posttrombotick\u00e9ho syndromu, prevence recidivy TEN.<\/li>\n<\/ol>\n<p>L\u00e9\u010dba je antikoagula\u010dn\u00ed, kompresivn\u00ed, trombolytick\u00e1a chirurgick\u00e1<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Antikoagula\u010dn\u00ed<\/strong><br \/>\nAntikoagula\u010dn\u00ed l\u00e9\u010dba, jak vypl\u00fdv\u00e1 z n\u00e1zvu, nerozpou\u0161t\u00ed tromb\u00f3zu (nejde o trombolytickou l\u00e9\u010dbu),ale sni\u017euje krevn\u00ed sr\u00e1\u017elivosti, a t\u00edm usnad\u0148uje a urychluje spont\u00e1nn\u00ed (endogenn\u00ed) plazmatickou fibrinol\u00fdzu. P\u0159i spr\u00e1vn\u011b veden\u00e9 l\u00e9\u010db\u011b je b\u011bhem3 m\u011bs\u00edc\u016f alespo\u0148 \u010d\u00e1ste\u010dn\u011b rekanalizov\u00e1no 99%\u00a0posti\u017een\u00fdch \u017eiln\u00edch segment\u016f (Haenen, 2001).Antikoagula\u010dn\u00ed l\u00e9\u010dba spo\u010d\u00edv\u00e1 v pod\u00e1v\u00e1n\u00ed:<\/p>\n<ol>\n<li style=\"text-align: justify;\"><strong>parenter\u00e1ln\u00edch heparin\u016f<\/strong> (nefrakcionovan\u00fd heparin &#8211; UFH, n\u00edzkomolekul\u00e1rn\u00ed hepariny &#8211; LMWH, u n\u00e1s nadroparin\/Fraxiparine, enoxaparin\/Clexane, dalteparin\/Fragmin), kter\u00e9 zahajuj\u00ed l\u00e9\u010dbu TEN. LMWH umo\u017e\u0148uj\u00ed dom\u00e1c\u00ed l\u00e9\u010dbu flebotromb\u00f3zy u vybran\u00fdch pacient\u016f(dob\u0159e spolupracuj\u00edc\u00ed, mlad\u0161\u00ed pacienti s dist\u00e1ln\u00ed flebotromb\u00f3zou \u2013 b\u00e9rcov\u00e9 \u017e\u00edly a svalov\u00e9 \u017e\u00edly b\u00e9rce),<\/li>\n<li style=\"text-align: justify;\"><strong>peror\u00e1ln\u00edch antagonist\u016f vitaminu K<\/strong> (warfarin), kter\u00e9 se pou\u017e\u00edvaj\u00ed v dlouhodob\u00e9 l\u00e9\u010db\u011b a prevenci TEN. Hepariny v krevn\u00ed plazm\u011b nep\u0159\u00edmo blokuj\u00ed aktivovan\u00e9 plazmatick\u00e9 koagula\u010dn\u00ed faktory (FIIa, FXa). LMWH inaktivuj\u00ed zejm\u00e9na FXa, ji\u017e m\u00e9n\u011b trombin (FIIa). Antagonist\u00e9 vitaminu K blokuj\u00ed synt\u00e9zu plazmatick\u00fdch faktor\u016f (F II, F V, F VII, F IX, F X, F XI) v j\u00e1trech kompetic\u00ed s vitaminem K.<\/li>\n<\/ol>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Kompresivn\u00ed terapie<\/strong><br \/>\nKomprese vy pr\u00e1zdn\u00ed povrchov\u00fd \u017eiln\u00ed syst\u00e9m a urychl\u00ed krevn\u00ed n\u00e1vrat. T\u00edm se sn\u00ed\u017e\u00ed otok a bolestivost doln\u00ed kon\u010detiny. <strong>Kompresivn\u00ed l\u00e9\u010dba tak\u00e9 p\u0159edstavuje d\u016fle\u017eitou prevenci plicn\u00ed embolie a pozd\u011bj\u0161\u00edho rozvoje posttrombotick\u00e9ho syndromu<\/strong> (Kahn, 2004) (Tab. 8). Pokud nemocn\u00e9ho neomezuje bolest nebo otok doln\u00ed kon\u010detiny (phlegmasia) a je kardiopulmon\u00e1ln\u011b kompenzovan\u00fd, mus\u00ed chodit, nesm\u00ed z\u016fstat le\u017eet na l\u016f\u017eku!<\/li>\n<li style=\"text-align: justify;\"><strong>Trombol\u00fdza<\/strong><br \/>\nTrombol\u00fdza je indikov\u00e1na u osob mlad\u0161\u00edch 50 let s rozs\u00e1hlou ileofemor\u00e1ln\u00ed flebotromb\u00f3zu, pokud klinick\u00e9 zn\u00e1mky trvaj\u00ed m\u00e9n\u011b ne\u017e t\u00fdden a nen\u00ed zv\u00fd\u0161en\u00e9 riziko krv\u00e1cen\u00ed (aktivn\u00ed n\u00e1dor, nekorigovan\u00e1 t\u011b\u017ek\u00e1 arteri\u00e1ln\u00ed hypertenze, recentn\u00ed operace, porod, aktivn\u00ed v\u0159edov\u00e1 choroba gastroduodena,z\u00e1va\u017en\u00e1 hepatopatie), d\u00e1le u pacient\u016f s flebotromb\u00f3zou, kter\u00e1 ohro\u017euje kon\u010detinu <em>(phlegmasia cerulea dolens).<\/em><\/p>\n<ul>\n<li style=\"text-align: justify;\">Mobilizace pacienta \u2013 pokud v ch\u016fzi nebr\u00e1n\u00ed otok nebo bolesti DK, kardiopulmon\u00e1ln\u00ed dekompenzace \u010di hypoxie p\u0159i plicn\u00ed embolii.<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00e1 trombektomie \u2013 Fogartyho kat\u00e9tr p\u0159i akutn\u00edm ohro\u017een\u00ed DK, pokud je lok\u00e1ln\u00ed trombol\u00fdza neprovediteln\u00e1.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h6>PREVENCE<\/h6>\n<p style=\"text-align: justify;\">Dlouhodob\u00e1 prim\u00e1rn\u00ed nebo sekund\u00e1rn\u00ed prevence TEN se v\u011bt\u0161inou prov\u00e1d\u00ed peror\u00e1ln\u00edmi antagonisty vitam\u00ednu K (kumariny). V\u00fdjimku tvo\u0159\u00ed nemocn\u00ed s aktivn\u00edm n\u00e1dorem, u kter\u00fdch LMWH sni\u017euj\u00ed v porovn\u00e1n\u00ed s kumariny riziko recidivy na polovinu, p\u0159i srovnateln\u00e9m nebezpe\u010d\u00ed krv\u00e1cen\u00ed. U ostatn\u00edch skupin nemocn\u00fdch je riziko recidivy TEN a krv\u00e1cen\u00ed p\u0159i pod\u00e1v\u00e1n\u00ed kumarin\u016f a heparin\u016f obdobn\u00e9. V sekund\u00e1rn\u00ed prevenci TEN kumariny v prvn\u00edch 3 m\u011bs\u00edc\u00edch sni\u017euj\u00ed riziko recidivy TEN asi o 90%, p\u0159i del\u0161\u00edm pod\u00e1v\u00e1n\u00ed tento jejich ochrann\u00fd vliv kles\u00e1 a nar\u016fst\u00e1 riziko velk\u00e9ho krv\u00e1cen\u00ed. Proto by m\u011bla b\u00fdt dlouhodob\u00e1 antikoagula\u010dn\u00ed l\u00e9\u010dba n\u00e1le\u017eit\u011b zv\u00e1\u017eena a zd\u016fvodn\u011bna trvaj\u00edc\u00edm v\u00fdznamn\u00fdm rizikem recidivy TEN.<\/p>\n<p style=\"text-align: justify;\">V t\u011bhotenstv\u00ed a \u0161estined\u011bl\u00ed se v l\u00e9\u010db\u011b a profylaxi TEN tak\u00e9 pou\u017e\u00edvaj\u00ed UFH nebo LMWH. Jejich bezpe\u010dnost a \u00fa\u010dinnost je srovnateln\u00e1.<\/p>\n<p style=\"text-align: justify;\">Trv\u00e1n\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dby v sekund\u00e1rn\u00ed prevenci TEN se mus\u00ed op\u00edrat o hodnocen\u00ed aktu\u00e1ln\u00edho rizika recidivy TEN, o hodnocen\u00ed rizika krv\u00e1cen\u00ed a o preference nemocn\u00e9ho.<\/p>\n<h4>10.2.3 Cestovn\u00ed tromb\u00f3za<\/h4>\n<p style=\"text-align: justify;\">B\u011bhem mnohahodinov\u00e9 imobilizace, a tedy i p\u0159i dlouh\u00e9m cestov\u00e1n\u00ed ve st\u00edsn\u011bn\u00fdch prostorech auta, autobusu \u010di letadla, m\u016f\u017ee vzniknout flebotromb\u00f3za. Tento fenom\u00e9n byl v odborn\u00e9 literatu\u0159e pojmenov\u00e1n\u201esyndrom ekonomick\u00e9 (turistick\u00e9) t\u0159\u00eddy\u201c a sna\u017eil se zd\u016fraznit vliv znehybn\u011bn\u00ed a tlaku hrany seda\u010dky v dopravn\u00edm letadle na vznik venost\u00e1zy a n\u00e1sledn\u00e9 flebotromb\u00f3zy v doln\u00edch kon\u010detin\u00e1ch. Ve vy\u0161\u0161\u00ed t\u0159\u00edd\u011b, kde je v\u00edce prostoru a mo\u017enost\u00ed pohybu, by se tento vliv podle autor\u016f uplat\u0148ovat nem\u011bl.<\/p>\n<p style=\"text-align: justify;\">Obecn\u011b cestov\u00e1n\u00ed na dlouh\u00e9 vzd\u00e1lenosti zvy\u0161uje riziko flebotromb\u00f3zy asi dvojn\u00e1sobn\u011b a riziko spojen\u00e9 s leteckou dopravou se neli\u0161\u00ed od rizika cestov\u00e1n\u00ed autem, autobusem nebo vlakem. Nebezpe\u010d\u00ed cestovn\u00ed flebotromb\u00f3zy v\u0161ak nen\u00ed u ka\u017ed\u00e9ho cestuj\u00edc\u00edho stejn\u00e9, zvy\u0161uje se zejm\u00e9na u osob s Leidenskou mutac\u00ed faktoru V, se zv\u00fd\u0161en\u00fdm BMI nad 30 kg\/m<sup>2<\/sup>, vy\u0161\u0161\u00edch ne\u017e 190 cm a u \u017een u\u017e\u00edvaj\u00edc\u00edch hormon\u00e1ln\u00ed antikoncepci.<\/p>\n<h4>10.2.4 Phlegmasia dolens<\/h4>\n<p style=\"text-align: justify;\">Jde o vz\u00e1cnou komplikaci rozs\u00e1hl\u00e9 \u017eiln\u00ed tromb\u00f3zy s nekrotickou devastac\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed, kdy je t\u00e9m\u011b\u0159 zastaven odtok \u017eiln\u00ed krve z kon\u010detiny. Vy\u0161\u0161\u00ed v\u00fdskyt je popisov\u00e1n u pacient\u016f s n\u00e1dorem (Trousseau\u016fv syndrom) nebo u jin\u00fdch z\u00e1va\u017en\u00fdch stav\u016f (nekrotizuj\u00edc\u00ed pankreatitida).<\/p>\n<p style=\"text-align: justify;\">Flegmazie se vyskytuje ve dvou klinick\u00fdch form\u00e1ch:<\/p>\n<ol>\n<li>\n<div style=\"text-align: justify;\"><strong>Phlegmasia alba dolens<\/strong> \u2013 vznik\u00e1 p\u0159i rozs\u00e1hl\u00e9 tromb\u00f3ze hlubok\u00fdch \u017eil p\u00e1nve, stehna a povrchov\u00fdch \u017eil doln\u00ed kon\u010detiny, se zachoval\u00fdm kolater\u00e1ln\u00edm hlubok\u00fdm \u017eiln\u00edm syst\u00e9mem. Klinicky je patrn\u00fd rozs\u00e1hl\u00fd otok jedn\u00e9 doln\u00ed kon\u010detiny, kter\u00e1 je bled\u00e1 a siln\u011b spont\u00e1nn\u011b bolestiv\u00e1, zejm\u00e9na p\u0159i sv\u011b\u0161en\u00ed.Tato m\u00edrn\u011bj\u0161\u00ed forma flegmazie je spojen\u00e1 s men\u0161\u00edm rizikem \u017eiln\u00ed gangr\u00e9ny a amputace. Vz\u00e1cn\u011b m\u016f\u017ee flegmazie postihnout ob\u011b doln\u00ed kon\u010detiny sou\u010dasn\u011b.<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\"><b>Phlegmasia coerulea dolens <\/b>\u2013 z\u00e1va\u017en\u00e1 forma flegmazie, kdy je akutn\u00ed masivn\u00ed tromb\u00f3zou posti\u017een\u00fd nejenom hlubok\u00fd a povrchov\u00fd \u017eiln\u00ed syst\u00e9m, ale tak\u00e9 \u017eiln\u00ed kolater\u00e1ly (svalov\u00e9 kolater\u00e1ly a mikrokolater\u00e1ly). Tepny jsou posti\u017een\u00e9 v\u00fdrazn\u00fdm spazmem. Klinick\u00fd obraz je charakterizovan\u00fd tri\u00e1dou: otok, cyan\u00f3za a ischemick\u00e1 bolest. Posti\u017een\u00e1 kon\u010detina je otekl\u00e1, v\u00fdrazn\u011b bolestiv\u00e1, na k\u016f\u017ei se objevuj\u00ed nepravideln\u00e9 modr\u00e9 cyanotick\u00e9 skvrny. Na stehenn\u00ed tepn\u011b v t\u0159\u00edsle, na podkolenn\u00ed tepn\u011b ani na <i>a. dorsalis pedis <\/i>nebo <i>a. tibialis posterior <\/i>nelze nahmatat pulzace. \u010casto vznik\u00e1 \u017eiln\u00ed gangr\u00e9na a kompartmentov\u00fd syndrom s vysok\u00fdm rizikem amputace kon\u010detiny nebo smrti.<br \/>\nU t\u00e9to z\u00e1va\u017en\u00e9 formy \u017eiln\u00ed tromb\u00f3zy je diagnostika snadn\u00e1 a jednozna\u010dn\u00e1 ji\u017e na z\u00e1klad\u011b klinick\u00e9ho vy\u0161et\u0159en\u00ed. Pomocn\u00e9 laboratorn\u00ed metody (ultrazvuk, CT nebo MRI) up\u0159esn\u00ed rozsah \u017eiln\u00ed a arteri\u00e1ln\u00ed obliterace a ur\u010d\u00ed velikost nekrotick\u00e9ho posti\u017een\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed. Rychl\u00e1 diagnostika a zah\u00e1jen\u00ed l\u00e9\u010dby jsou nejlep\u0161\u00ed prevenc\u00ed \u017eiln\u00ed gangr\u00e9ny, amputace kon\u010detiny a smrti nemocn\u00e9ho (obr. 7\u20139).<\/div>\n<\/li>\n<\/ol>\n<h6>L\u00c9\u010cBA<\/h6>\n<p style=\"text-align: justify;\">Celkov\u00fd z\u00e1va\u017en\u00fd stav vy\u017eaduje klid na l\u016f\u017eku s elevac\u00ed posti\u017een\u00e9 kon\u010detiny. K zpr\u016fchodn\u011bn\u00ed c\u00e9vn\u00edho \u0159e\u010di\u0161t\u011b se pou\u017e\u00edv\u00e1 antikoagulace hepariny, trombol\u00fdza a chirurgick\u00e1 trombektomie.<\/p>\n<h4>10.2.5 Posttrombotick\u00fd syndrom<\/h4>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o chronick\u00fd stav, kter\u00fd se b\u011bhem 1\u20132 let rozv\u00edj\u00ed u 20\u201350% pacient\u016f po symptomatick\u00e9 flebotromb\u00f3ze (Kahn, 2004). Patofyziologick\u00fdm podkladem je ambulantn\u00ed \u017eiln\u00ed hypertenze v d\u016fsledku sekund\u00e1rn\u00ed chlopenn\u00ed \u017eiln\u00ed nedostate\u010dnosti a\/nebo zbytkov\u00e9 \u017eiln\u00ed obstrukce. Nejz\u00e1va\u017en\u011bj\u0161\u00ed klinick\u00e9 projevy maj\u00ed nemocn\u00ed, u kter\u00fdch se kombinuje chlopenn\u00ed \u017eiln\u00ed insuficience s \u017eiln\u00ed obstrukc\u00ed.<\/p>\n<p style=\"text-align: justify;\">Klinicky je syndrom charakterizov\u00e1n chronickou bolest\u00ed, otokem a trofick\u00fdmi zm\u011bnami k\u016f\u017ee a podko\u017e\u00ed posti\u017een\u00e9 kon\u010detiny. U \u010dtvrtiny a\u017e t\u0159etiny nemocn\u00fdch se objevuje chronick\u00fd \u017eiln\u00ed v\u0159ed.<\/p>\n<p style=\"text-align: justify;\">Pro diagnostiku posttrombotick\u00e9ho syndromu m\u00e1 v\u00fdznam p\u0159\u00edtomnost klinick\u00fdch projevech, flebotromb\u00f3za v anamn\u00e9ze a ultrasonografick\u00fd pr\u016fkaz \u017eiln\u00ed insuficienci (chlopenn\u00ed dysfunkce) a\/nebo obstrukci.<\/p>\n<p style=\"text-align: justify;\">L\u00e9\u010debn\u00e9 mo\u017enosti jsou zde mezen\u00e9, spo\u010d\u00edvaj\u00ed v podstat\u011b v no\u0161en\u00ed kompresivn\u00edch pun\u010doch a pod\u00e1van\u00ed venofarmak.<\/p>\n<table style=\"border: 0px solid #ffffff; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 33%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_313.jpg\"><img decoding=\"async\" class=\"  \" title=\"Obr. 7 - Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed\" alt=\"Obr. 7 - Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_313.jpg\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 7<br \/>Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed<\/p><\/div><\/td>\n<td style=\"width: 33%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_314.jpg\"><img decoding=\"async\" class=\" \" title=\"Obr. 8 - Phlegmasia coerulea dolens v pr\u016fb\u011bhu l\u00e9\u010dby\" alt=\"Obr. 8 - Phlegmasia coerulea dolens v pr\u016fb\u011bhu l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_314.jpg\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 8<br \/>Phlegmasia coerulea dolens v pr\u016fb\u011bhu l\u00e9\u010dby<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_315.jpg\"><img decoding=\"async\" class=\" \" title=\"Obr. 9 - Phlegmasia coerulea dolens na konci l\u00e9\u010dby\" alt=\"Obr. 9 - Phlegmasia coerulea dolens na konci l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_315.jpg\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 9<br \/>Phlegmasia coerulea dolens na konci l\u00e9\u010dby<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.a<\/span><br \/>\n<!--nextpage--><\/p>\n<h3><span style=\"font-size: 1.17em;\">10.3 Diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed<\/span><\/h3>\n<h4>10.3.1 Klinick\u00e1 diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed \u2013 anamn\u00e9za<\/h4>\n<p style=\"text-align: justify;\">V klinick\u00e9 praxi se nej\u010dast\u011bji setk\u00e1me s \u017eiln\u00ed insuficienc\u00ed a \u017eiln\u00ed tromb\u00f3zou. \u017diln\u00ed malformace a aneuryzmata jsou vz\u00e1cn\u00e9. \u017diln\u00ed tromb\u00f3za se m\u016f\u017ee vyskytnou v jak\u00e9mkoliv v\u011bku, ale v d\u011btstv\u00ed je u zdrav\u00fdch jedinc\u016f extr\u00e9mn\u011b vz\u00e1cn\u00e1. U mlad\u00fdch \u017een vznik\u00e1 \u017eiln\u00ed tromb\u00f3za nej\u010dast\u011bji v souvislosti s u\u017e\u00edv\u00e1n\u00edm hormon\u00e1ln\u00ed antikoncepce.<\/p>\n<p style=\"text-align: justify;\">Tromb\u00f3za povrchov\u00fdch (podko\u017en\u00edch, epifasci\u00e1ln\u00edch) \u017eil je \u010dast\u00e1 na doln\u00edch kon\u010detin\u00e1ch, zejm\u00e9na pokud pacient trp\u00ed varixy (varikoflebitida). Na horn\u00edch kon\u010detin\u00e1ch je tromboflebitida vz\u00e1cn\u00e1, v\u011bt\u0161inou iatrogenn\u011b podm\u00edn\u011bn\u00e1, objevuj\u00edc\u00ed se po kanylaci \u017e\u00edly. Spont\u00e1nn\u00ed tromboflebitidy mohou ohla\u0161ovat malign\u00ed onemocn\u011bn\u00ed, trombofilii nebo syst\u00e9mov\u00e1 onemocn\u011bn\u00ed.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Rodinn\u00e1 anamn\u00e9za<\/strong><br \/>\nKl\u00ed\u010dem rodinn\u00e9 predispozice ke vzniku flebotromb\u00f3zy jsou \u00fadaje o amputac\u00edch kon\u010detin (flegmazie),opakovan\u00fdch potratech a p\u0159ed\u010dasn\u00fdch porodech,o n\u00e1hl\u00fdch \u00famrt\u00edch ve v\u011bku do 50 let, o v\u00fdskytu flebotromb\u00f3zy u dal\u0161\u00edch \u010dlen\u016f rodiny, zejm\u00e9na potom opakovan\u00e9 flebotromb\u00f3zy \u00a0\u017eiln\u00ed uz\u00e1v\u011bry v atypick\u00fdch oblastech (\u017e\u00edly horn\u00edch kon\u010detin, viscer\u00e1ln\u00ed \u017e\u00edly, mozkov\u00e9 splavy).<\/li>\n<li style=\"text-align: justify;\"><strong>Osobn\u00ed anamn\u00e9za<\/strong><br \/>\nTady jsou d\u016fle\u017eit\u00e9 \u00fadaje o prod\u011blan\u00fdch erysipelech,operac\u00edch a \u00farazech doln\u00edch kon\u010detin, tromboflebitid\u00e1ch a flebotromb\u00f3z\u00e1ch.<\/li>\n<li style=\"text-align: justify;\"><strong>L\u00e9kov\u00e1 anamn\u00e9za<\/strong><br \/>\nPt\u00e1me se na intraven\u00f3zn\u00ed aplikaci l\u00e9\u010div, zejm\u00e9na hyperosmol\u00e1rn\u00edch roztok\u016f (chemick\u00e1 irita\u010dn\u00ed tromboflebitida a flebotromb\u00f3za), na u\u017e\u00edv\u00e1n\u00ed hormon\u00e1ln\u00ed antikoncepce \u010di substitu\u010dn\u00ed hormon\u00e1ln\u00edl\u00e9\u010dby, psychiatrick\u00fdch l\u00e9k\u016f (antipsychotika, anticholinergika).<\/li>\n<li style=\"text-align: justify;\"><strong>Pracovn\u00ed anamn\u00e9za<\/strong><br \/>\nJe d\u016fle\u017eit\u00e1 u \u017eiln\u00edch onemocn\u011bn\u00ed doln\u00edch kon\u010detin. \u017diln\u00ed insuficience se vyskytuje \u010dast\u011bji u profes\u00ed,kter\u00e9 v\u011bt\u0161inu \u010dasu tr\u00e1v\u00ed vsed\u011b nebo vestoje \u2013 zuba\u0159i, prodava\u010dky, kade\u0159nice, holi\u010di, \u010d\u00ed\u0161n\u00edci, \u0159idi\u010di,pokladn\u00ed, skladn\u00edci atd. Zam\u011bstn\u00e1n\u00ed nebo sporty \u00a0s velkou fyzickou z\u00e1t\u011b\u017e\u00ed horn\u00edch a doln\u00edch kon\u010detin(\u0159ezn\u00edci, d\u011bln\u00edci) predisponuj\u00ed ke vzniku \u017eiln\u00ed tromb\u00f3zy doln\u00edch kon\u010detin nebo flebotromb\u00f3zy nam\u00e1han\u00e9 horn\u00ed kon\u010detiny (n\u00e1mahov\u00e1 flebotromb\u00f3za,effort thrombosis).<\/li>\n<\/ul>\n<h4>10.3.2 Klinick\u00e9 projevy \u017eiln\u00edch onemocn\u011bn\u00ed<\/h4>\n<p style=\"text-align: justify;\"><strong>Mezi hlavn\u00ed klinick\u00e9 projevy \u017eiln\u00edch onemocn\u011bn\u00ed pat\u0159\u00ed otok, barevn\u00e9 zm\u011bny k\u016f\u017ee v m\u00edst\u011b otoku, lok\u00e1ln\u00ed bolestivost (spont\u00e1nn\u00ed, palpa\u010dn\u00ed nebo n\u00e1mahov\u00e1) a na doln\u00edch kon\u010detin\u00e1ch pocity t\u00edhy, \u00fanavy, bolesti a no\u010dn\u00ed svalov\u00e9 k\u0159e\u010de<\/strong>. U konkr\u00e9tn\u00edho pacienta nemus\u00ed b\u00fdt nutn\u011b sou\u010dasn\u011b vyj\u00e1d\u0159eny v\u0161echny symptomy. Jindy \u017eiln\u00ed onemocn\u011bn\u00ed prob\u00edh\u00e1 zcela asymptomaticky \u010di s nespecifick\u00fdmi projevy.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Fyzik\u00e1ln\u00ed (objektivn\u00ed) vy\u0161et\u0159en\u00ed kon\u010detin<\/strong><br \/>\nNejjednodu\u0161eji a nejspolehliv\u011bji lze z\u00edskat objektivn\u00ed informaci o posti\u017een\u00e9 kon\u010detin\u011b pohledem a pohmatem a jej\u00edm srovn\u00e1n\u00edm s kontralater\u00e1ln\u00ed kon\u010detinou. Doln\u00ed kon\u010detiny mus\u00edme vy\u0161et\u0159it vle\u017ee i vestoje.<\/li>\n<li style=\"text-align: justify;\"><strong>Pohledem zji\u0161\u0165ujeme:<\/strong><br \/>\notok, hypertrofii, zm\u011bny barvy, p\u0159\u00edtomnost podko\u017en\u00edch \u017eiln\u00edch kolater\u00e1l, jizvy a m\u00edsta vpich\u016f, zn\u00e1mky prob\u011bhl\u00e9ho traumatu, zaveden\u00ed \u017eiln\u00edch kanyl, ko\u017en\u00ed exkoriace a trofick\u00e9 zm\u011bny.<\/li>\n<li style=\"text-align: justify;\"><strong>Pohmatem zji\u0161\u0165ujeme<\/strong>:<br \/>\nteplotu kon\u010detiny nebo jej\u00edch \u010d\u00e1st\u00ed, citlivost v pr\u016fb\u011bhu posti\u017een\u00e9 podko\u017en\u00ed \u017e\u00edly, v nadkl\u00ed\u010dkov\u00e9 jamce nebo v axile, zv\u011bt\u0161en\u00ed lymfatick\u00fdch uzlin (p\u0159\u00ed\u010dina zevn\u00ed \u017eiln\u00ed obstrukce, zn\u00e1mka z\u00e1n\u011btu k\u016f\u017ee a podko\u017e\u00ed), hmatn\u00e9 tuh\u00e9 podko\u017en\u00ed \u017e\u00edly po prob\u011bhl\u00e9 tromboflebitid\u011b, p\u0159\u00edtomnost pulzac\u00ed na zvykl\u00fdch m\u00edstech nebo naopak abnorm\u00e1ln\u00ed pulzace (arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble, c\u00e9vn\u00ed malformace), p\u0159\u00edtomnost ed\u00e9mu.<\/li>\n<li style=\"text-align: justify;\">Pr\u016fb\u011bh podko\u017en\u00edch \u017eil, zejm\u00e9na pokud jde o kmenovou insuficienci velk\u00e9 a mal\u00e9 safeny, lze ov\u011b\u0159it lehk\u00fdm <b>p\u0159\u00edm\u00fdm poklepem<\/b>. Perkuz\u00ed na varix p\u0159i sou\u010dasn\u00e9 lehk\u00e9 palpaci druhou rukou nad nebo pod m\u00edstem poklepu lze vystopovat jeho pr\u016fb\u011bh. Tento man\u00e9vr je vhodn\u00fd zejm\u00e9na u ob\u00e9zn\u00edch osob, kde nejsou podko\u017en\u00ed \u017e\u00edly viditeln\u00e9.<\/li>\n<li style=\"text-align: justify;\"><strong>Auskultac\u00ed<\/strong> p\u00e1tr\u00e1me po \u0161elestech (arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble, c\u00e9vn\u00ed malformace). P\u0159i vy\u0161et\u0159en\u00ed jednostrann\u00e9ho otoku horn\u00ed kon\u010detiny nesm\u00edme zapomenout na pohmat axily k vylou\u010den\u00ed lymfadenopatie a u \u017een na mamologick\u00e9 vy\u0161et\u0159en\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>\u017diln\u00ed otok<\/strong><br \/>\nOtok je nahromad\u011bn\u00ed interstici\u00e1ln\u00ed tekutiny (tk\u00e1\u0148ov\u00e9ho moku) v mezibun\u011b\u010dn\u00e9m vazivov\u00e9m prostoru (intersticiu), tj. v extracelul\u00e1rn\u00edm a extrakapil\u00e1rn\u00edm (extravaz\u00e1ln\u00edm) kompartmentu. V p\u0159\u00edpad\u011b \u017eiln\u00edho otoku je d\u016fvodem hromad\u011bn\u00ed interstici\u00e1ln\u00ed tekutiny nadm\u011brn\u00e1 filtrace plazmy z krevn\u00edch kapil\u00e1r do intersticia p\u0159i zv\u00fd\u0161en\u00e9m intrakapil\u00e1rn\u00edm hydrostatick\u00e9m tlaku. P\u0159\u00ed\u010dinou je m\u011bstn\u00e1n\u00ed \u017eiln\u00ed a kapil\u00e1rn\u00ed krve a\/nebo vazodilatace. Voln\u00e1 (nebun\u011b\u010dn\u00e1) tekutina se hromad\u00ed v k\u016f\u017ei a podko\u017e\u00ed.<\/li>\n<\/ul>\n<h6>DIFERENCI\u00c1LN\u00cd DIAGNOSTIKA \u017dILN\u00cdHO OTOKU<\/h6>\n<p>P\u0159i podez\u0159en\u00ed na \u017eiln\u00ed otok mus\u00edme vylou\u010dit n\u011bkter\u00e9 dal\u0161\u00ed patologick\u00e9 stavy, kter\u00e9 jej mohou napodobovat:<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Liped\u00e9m<\/strong> je b\u011b\u017en\u00e9, zato velmi z\u0159\u00eddka diagnostikovan\u00e9 posti\u017een\u00ed doln\u00edch kon\u010detin, vyskytuj\u00edc\u00ed se t\u00e9m\u011b\u0159 v\u00fdhradn\u011b u \u017een. Je zam\u011b\u0148ov\u00e1n za obezitu, \u010dasto ho ale gynoidn\u00ed typ obezity (h\u00fd\u017ed\u011b, stehna) prov\u00e1z\u00ed.<strong> Tukov\u00e1 podko\u017en\u00ed tk\u00e1\u0148 liped\u00e9mu symetricky obaluje ob\u011b doln\u00ed kon\u010detiny od t\u0159\u00edsel po kotn\u00edky, v\u011bt\u0161inou je p\u0159\u00edtomn\u00fd tak\u00e9 lymfed\u00e9m.<\/strong> Vynech\u00e1v\u00e1 n\u00e1rty nohou, kde nen\u00ed podko\u017en\u00ed tukov\u00e1 tk\u00e1\u0148. Pokud se objev\u00ed otok n\u00e1rtu, jde o projev p\u0159idru\u017een\u00e9ho lymfed\u00e9mu. Charakteristick\u00fdmi vlastnostmi liped\u00e9mu jsou spont\u00e1nn\u00ed bolestivost, bolestivost p\u0159i tlaku rukou nebo ultrazvukovou sondou, zejm\u00e9na na medi\u00e1ln\u00ed stran\u011b stehen, a tendence k \u010dast\u00fdm podko\u017en\u00edm hematom\u016fm. Nelze v n\u011bm vytla\u010dit d\u016flek jako p\u0159i nahromad\u011bn\u00ed interstici\u00e1ln\u00ed tekutiny, ale jsou patrn\u00e9 drobn\u00e9 dol\u00ed\u010dky, zejm\u00e9na na stehnech. Je to projev lipodystrofie, m\u00edstn\u00ed drobn\u00e9 nepravidelnosti a \u00fabytku tukov\u00e9 tk\u00e1n\u011b a kolagenn\u00edho podko\u017en\u00edho vaziva, nespr\u00e1vn\u011b ozna\u010dovan\u00e9 jako celulitida.<\/li>\n<li style=\"text-align: justify;\"><strong>Myxed\u00e9m<\/strong> vznik\u00e1 p\u0159i hypotyre\u00f3ze zdu\u0159en\u00edm koriov\u00fdch vl\u00e1ken a nahromad\u011bn\u00edm mukoidn\u00edch hmot v podko\u017e\u00ed. Je tuh\u00fd, k\u016f\u017ee na povrchu je such\u00e1, hrub\u00e1 a na\u017eloutl\u00e1. Postihuje obli\u010dej, k\u016f\u017ei na h\u0159betu rukou a nohou. Na ventr\u00e1ln\u00ed a later\u00e1ln\u00ed stran\u011b b\u00e9rce se objevuje ohrani\u010den\u00fd pretibi\u00e1ln\u00ed myxed\u00e9m. Rozsahem b\u00fdv\u00e1 velk\u00fd asi jako dla\u0148, ale n\u011bkdy m\u016f\u017ee sahat a\u017e na h\u0159bet nohy.<\/li>\n<li style=\"text-align: justify;\"><strong>Hypertrofie podko\u017en\u00ed tk\u00e1n\u011b<\/strong> \u2013 postihuje asymetricky jednu doln\u00ed kon\u010detinu nebo jej\u00ed \u010d\u00e1st (noha, prsty) u Klippelova-Trenaunayova syndromu a Parkesova-Weberova syndromu. M\u016f\u017ee imitovat otok, zejm\u00e9na v kombinaci s varixy, atypick\u00fdmi podko\u017en\u00edmi \u017e\u00edlami a difuzn\u00edmi kapil\u00e1rn\u00edmi malformacemi, kter\u00e9 se zde vyskytuj\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>Lymfed\u00e9m<\/strong> \u2013 postihuje p\u0159edev\u0161\u00edm akr\u00e1ln\u00ed \u010d\u00e1sti horn\u00ed a doln\u00ed kon\u010detiny (prsty, n\u00e1rty, kotn\u00edky, dorzum ruky) a \u0161\u00ed\u0159\u00ed se proxim\u00e1ln\u011b. Ostatn\u00ed \u010d\u00e1sti t\u011bla jsou posti\u017een\u00e9 z\u0159\u00eddka. M\u016f\u017ee se objevit na jedn\u00e9 nebo na obou doln\u00edch kon\u010detin\u00e1ch (tab. 1 a 2), na horn\u00edch kon\u010detin\u00e1ch je jednostrann\u00fd (stavy po ablaci prsu s n\u00e1slednou radioterapi\u00ed). V \u010dasn\u00fdch stadi\u00edch ho p\u0159i klinick\u00e9m vy\u0161et\u0159en\u00ed nelze odli\u0161it od \u017eiln\u00edho otoku. Je m\u011bkk\u00fd, lze do n\u011bj vytla\u010dit d\u016flek, je reverzibiln\u00ed, do r\u00e1na ustupuje nebo zcela miz\u00ed. Od \u017eiln\u00edho otoku se za\u010d\u00edn\u00e1 odli\u0161ovat a\u017e po n\u011bkolika t\u00fddnech nebo m\u011bs\u00edc\u00edch, kdy je tuh\u00fd, bled\u0161\u00ed ne\u017e okoln\u00ed k\u016f\u017ee, chladn\u011bj\u0161\u00ed, spont\u00e1nn\u011b a na tlak nebolestiv\u00fd, je zcela ireverzibiln\u00ed, b\u011bhem noci neustupuje, nem\u011bn\u00ed se.<\/li>\n<li style=\"text-align: justify;\"><strong>Angioneurotick\u00fd ed\u00e9m (Quinckeho ed\u00e9m)<\/strong><br \/>\nvznik\u00e1 p\u016fsoben\u00edm ur\u010dit\u00e9ho alergenu. Rozv\u00edj\u00ed se rychle a recidivuje. Nej\u010dast\u011bji postihuje tv\u00e1\u0159e, v\u00ed\u010dka a rty, m\u00e9n\u011b \u010dasto kon\u010detiny.<\/li>\n<\/ul>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\"><span style=\"color: #ffffff;\">Tabulka 1<\/span><br \/>\n<span style=\"color: #ffffff;\">Oboustrann\u00e9 otoky doln\u00edch kon\u010detin<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" width=\"30%\"><strong>Otok<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>P\u0159\u00ed\u010dina<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Statick\u00fd (\u201efyziologick\u00fd\u201c)<\/td>\n<td>imobilizace a vy\u0159azen\u00ed \u017eiln\u011b-svalov\u00e9 pumpy l\u00fdtka<\/td>\n<\/tr>\n<tr>\n<td>T\u011bhotensk\u00fd a premenstrua\u010dn\u00ed<\/td>\n<td>zadr\u017eov\u00e1n\u00ed sod\u00edku + zv\u00fd\u0161en\u00e1 kapil\u00e1rn\u00ed propustnost pro b\u00edlkovinu<\/td>\n<\/tr>\n<tr>\n<td>Alergick\u00fd (Quinckeho)<\/td>\n<td>dilatace arteriol a prekapil\u00e1rn\u00edch sv\u011bra\u010d\u016f + venokonstrikce + zv\u00fd\u0161en\u00ed kapil\u00e1rn\u00ed propustnosti p\u016fsoben\u00edm alergenu<\/td>\n<\/tr>\n<tr>\n<td>Pol\u00e9kov\u00fd (iatrogenn\u00ed)<\/td>\n<td>r\u016fzn\u00fd mechanismus podle druhu l\u00e9ku<\/td>\n<\/tr>\n<tr>\n<td>Srde\u010dn\u00ed<\/td>\n<td>sn\u00ed\u017een\u00ed srde\u010dn\u00edho v\u00fddeje + neurohumor\u00e1ln\u00ed zm\u011bny + zadr\u017een\u00ed vody a miner\u00e1l\u016f<\/td>\n<\/tr>\n<tr>\n<td>Ledvinn\u00fd<\/td>\n<td>zadr\u017een\u00ed vody a miner\u00e1l\u016f, hypoproteinemie<\/td>\n<\/tr>\n<tr>\n<td>Jatern\u00ed<\/td>\n<td>perifern\u00ed vazodilatace + neurohumor\u00e1ln\u00ed zm\u011bny<\/td>\n<\/tr>\n<tr>\n<td>Hypoproteinemick\u00fd<br \/>\n(hypoalbuminemie, an\u00e9mie)<\/td>\n<td>pokles onkotick\u00e9ho tlaku plazmy<\/td>\n<\/tr>\n<tr>\n<td>\u017diln\u00ed<\/td>\n<td>porucha \u017eiln\u011b-svalov\u00e9 pumpy, \u017eiln\u00ed hypertenze<\/td>\n<\/tr>\n<tr>\n<td>Prim\u00e1rn\u00ed lymfatick\u00fd<\/td>\n<td>porucha v\u00fdvoje lymfatick\u00fdch c\u00e9v + asymptomatick\u00fd z\u00e1n\u011bt?<\/td>\n<\/tr>\n<tr>\n<td>Liped\u00e9m<\/td>\n<td>nahromad\u011bn\u00ed tukov\u00e9 tk\u00e1n\u011b v podko\u017e\u00ed p\u0159i gynoidn\u00ed obezit\u011b<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.a<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\" scope=\"col\"><span style=\"color: #ffffff;\">Tabulka 2<\/span><br \/>\n<span style=\"color: #ffffff;\"> Jednostrann\u00e9 otoky doln\u00edch kon\u010detin<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" width=\"30%\"><strong>Otok<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>P\u0159\u00ed\u010dina\u00a0<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Flebotromb\u00f3za<\/td>\n<td>ucp\u00e1n\u00ed hlubok\u00fdch \u017eil doln\u00ed kon\u010detiny<\/td>\n<\/tr>\n<tr>\n<td>Tromboflebitida<\/td>\n<td>z\u00e1n\u011bt a ucp\u00e1n\u00ed podko\u017en\u00edch \u017eil doln\u00ed kon\u010detiny<\/td>\n<\/tr>\n<tr>\n<td>Posttrombotick\u00fd syndrom<\/td>\n<td>obstrukce + reflux v hlubok\u00fdch \u017eil\u00e1ch doln\u00ed kon\u010detiny vznikaj\u00edc\u00ed po prod\u011blan\u00e9 fl ebotromb\u00f3ze<\/td>\n<\/tr>\n<tr>\n<td>Lymfatick\u00fd<\/td>\n<td>nedostate\u010dn\u00fd v\u00fdvoj perifern\u00edch lymfatick\u00fdch c\u00e9v a uzlin = vrozen\u00fd lymfatick\u00fd otok, po\u0161kozen\u00ed perifern\u00edch lymfatick\u00fdch c\u00e9v a uzlin = sekund\u00e1rn\u00ed lymfatick\u00fd otok, porucha v\u00fdvoje lymfatick\u00fdch c\u00e9v + asymptomatick\u00fd z\u00e1n\u011bt? = prim\u00e1rn\u00ed lymfatick\u00fd otok<\/td>\n<\/tr>\n<tr>\n<td>\u017diln\u00ed<\/td>\n<td>porucha \u017eiln\u011b-svalov\u00e9 pumpy, \u017eiln\u00ed hypertenze<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.a<\/span><\/p>\n<h4>10.3.3 Laboratorn\u00ed diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed<\/h4>\n<h6>DIAGNOSTIKA \u017dILN\u00cd INSUFICIENCE<\/h6>\n<p style=\"text-align: justify;\">\u017diln\u00ed insuficienci lze diagnostikovat pouze na z\u00e1klad\u011b klinick\u00e9ho vy\u0161et\u0159en\u00ed \u2013 anamn\u00e9zy a objektivn\u00edho fyzik\u00e1ln\u00edho n\u00e1lezu.D\u016fvodem ultrazvukov\u00e9ho vy\u0161et\u0159en\u00ed v t\u00e9to f\u00e1zi mohou b\u00fdt:<\/p>\n<ol>\n<li style=\"text-align: justify;\">netypick\u00e9 subjektivn\u00ed pot\u00ed\u017ee,<\/li>\n<li style=\"text-align: justify;\">nev\u00fdrazn\u00fd objektivn\u00ed n\u00e1lez,<\/li>\n<li style=\"text-align: justify;\">zva\u017eov\u00e1n\u00ed jin\u00e9 p\u0159\u00ed\u010diny otok\u016f doln\u00edch kon\u010detin, zejm\u00e9na u symetrick\u00fdch otok\u016f, u ob\u00e9zn\u00edch a polymorbidn\u00edch pacient\u016f (nap\u0159. srde\u010dn\u00ed, jatern\u00ed a ledvinn\u00e1 onemocn\u011bn\u00ed),<\/li>\n<li style=\"text-align: justify;\">podez\u0159en\u00ed na spolupod\u00edl dal\u0161\u00edch lok\u00e1ln\u00edch faktor\u016f krom\u011b \u017eiln\u00ed insuficience, kter\u00e9 by mohly vyvol\u00e1vat subjektivn\u00ed pot\u00ed\u017ee v oblasti doln\u00edch kon\u010detin (Bakerova cysta p\u0159i gonartr\u00f3ze, tromboflebitida, flebotromb\u00f3za, podko\u017en\u00ed n\u00e1dory, zv\u011bt\u0161en\u00e9 lymfatick\u00e9 uzliny, cysty, v\u00fdpotky, hematomy atd.),<\/li>\n<li style=\"text-align: justify;\">podez\u0159en\u00ed na vrozen\u00e9 \u017eiln\u00ed malformace.<\/li>\n<\/ol>\n<p><span style=\"text-align: justify;\">Ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed \u017eil doln\u00edch kon\u010detin je nutn\u00e9 p\u0159ed ka\u017edou pl\u00e1novanou invazivn\u00ed l\u00e9\u010dbou \u017eiln\u00ed insuficience, v\u010detn\u011b skleroterapie. Chirurgick\u00e1 l\u00e9\u010dba varix\u016f doln\u00edch kon\u010detin se v posledn\u00edch letech zm\u011bnila. Ji\u017e se b\u011b\u017en\u011b neprov\u00e1d\u00ed tot\u00e1ln\u00ed striping velk\u00e9 safeny jako univerz\u00e1ln\u00ed opera\u010dn\u00ed postup. Z\u00e1kladn\u00edm principem je eliminace patologick\u00e9ho refluxu z hlubok\u00e9ho do povrchov\u00e9ho \u017eiln\u00edho syst\u00e9mu a odstran\u011bn\u00ed inkompetentn\u00edch \u017eiln\u00edch \u00fasek\u016f (Herman, 1999). Aby mohla b\u00fdt provedena operace takto c\u00edlen\u011b, je t\u0159eba ur\u010dit m\u00edsta insuficience.<\/span><\/p>\n<h6>DIAGNOSTIKA FLEBOTROMB\u00d3ZY<\/h6>\n<p style=\"text-align: justify;\">Pokud mluv\u00edme o diagnostice flebotromb\u00f3zy, m\u00e1me na mysli p\u0159edev\u0161\u00edm flebotromb\u00f3zu doln\u00edch kon\u010detin a ky\u010deln\u00edch \u017eil. Flebotromb\u00f3za v\u0161ak m\u016f\u017ee postihovat kteroukoliv \u010d\u00e1st \u017eiln\u00edho \u0159e\u010di\u0161t\u011b.Klinick\u00e1 diagn\u00f3za hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy je zna\u010dn\u011b zat\u00ed\u017een\u00e1 subjektivn\u00edm hodnocen\u00edm posti\u017een\u00e9 kon\u010detiny konkr\u00e9tn\u00edm l\u00e9ka\u0159em a <b>senzitivita klinick\u00e9ho vy\u0161et\u0159en\u00ed<\/b>, bez pou\u017eit\u00ed laboratorn\u00edch vy\u0161et\u0159en\u00ed, z\u0159ejm\u011b <b>nep\u0159ekra\u010duje 25\u201330%<\/b>. Spolehliv\u00e1 diagnostika pouze na z\u00e1klad\u011b anamn\u00e9zy a fyzik\u00e1ln\u00edho vy\u0161et\u0159en\u00ed je \u010dasto nemo\u017en\u00e1 nebo pochybn\u00e1. V\u017edy se mus\u00edme op\u0159\u00edt o pomocn\u00e1 laboratorn\u00ed vy\u0161et\u0159en\u00ed.Sou\u010dasn\u00e9 laboratorn\u00ed diagnostick\u00e9 metody k pr\u016fkazu flebotromb\u00f3zy m\u016f\u017eeme rozd\u011blit na <b>nep\u0159\u00edm\u00e9 a p\u0159\u00edm\u00e9<\/b>. Nep\u0159\u00edm\u00e9 diagnostick\u00e9 metody nezobrazuj\u00ed trombus v \u017eiln\u00edm \u0159e\u010di\u0161ti, pouze nep\u0159\u00edmo ukazuj\u00ed na jeho mo\u017enou p\u0159\u00edtomnost. Pat\u0159\u00ed sem vy\u0161et\u0159en\u00ed D-dim\u00e9r\u016f a fibrin degrada\u010dn\u00edch produkt\u016f v krevn\u00ed plazm\u011b a impedan\u010dn\u00ed pletyzmografie. P\u0159ednost se d\u00e1v\u00e1 p\u0159\u00edm\u00fdm zobrazovac\u00edm metod\u00e1m, kter\u00e9 umo\u017e\u0148uj\u00ed l\u00e9ka\u0159i p\u0159\u00edmo vid\u011bt trombus v \u017e\u00edle, posoudit rozsah tromb\u00f3zy a stupe\u0148 obliterace \u017eiln\u00edho lumen.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Nep\u0159\u00edm\u00e9 diagnostick\u00e9 metody<\/strong>\n<ol style=\"text-align: justify;\">\n<li><em style=\"text-align: justify;\">Impedan\u010dn\u00ed pletyzmografie (IPG)<br \/>\n<\/em>Impedan\u010dn\u00ed pletyzmografie je neinvazivn\u00ed vy\u0161et\u0159en\u00ed p\u016fvodn\u011b vyvinut\u00e9 NASA pro m\u011b\u0159en\u00ed impedance hrudn\u00edku p\u0159i srde\u010dn\u00ed akci, zalo\u017een\u00e9 na sn\u00edm\u00e1n\u00ed mal\u00fdch zm\u011bn elektrick\u00e9ho odporu t\u011bla. Elektrick\u00fd odpor tk\u00e1n\u00ed se m\u011bn\u00ed podle aktu\u00e1ln\u00edho obsahu krve. V doln\u00ed kon\u010detin\u011b se p\u0159i tromb\u00f3ze objem krve zv\u011bt\u0161uje a elektrick\u00fd odpor kles\u00e1 a nep\u0159\u00edmo tak indikuje p\u0159\u00edtomnost \u017eiln\u00ed tromb\u00f3zy. P\u0159i vy\u0161et\u0159en\u00ed se nafoukne pneumatick\u00e1 man\u017eeta kolem stehna tak, aby byl zcela p\u0159eru\u0161en\u00fd \u017eiln\u00ed tok p\u0159i zachov\u00e1n\u00ed tepenn\u00e9ho pr\u016ftoku, tak\u017ee \u017eiln\u00ed tlak v kon\u010detin\u011b stoupne na tlak v man\u017eet\u011b. P\u0159i vyfouknut\u00ed pneumatick\u00e9 man\u017eety za\u010dne \u017eiln\u00ed krev z kon\u010detiny rychle odt\u00e9kat, dokud nen\u00ed dosa\u017eeno klidov\u00e9ho (v\u00fdchoz\u00edho) krevn\u00edho objemu. P\u0159i \u017eiln\u00ed tromb\u00f3ze se tato reakce na p\u0159echodnou \u017eiln\u00ed obstrukci charakteristicky zm\u011bn\u00ed. N\u00e1r\u016fst objemu krve v posti\u017een\u00e9 kon\u010detin\u011b po nafouknut\u00ed man\u017eety bude men\u0161\u00ed ne\u017e ve zdrav\u00e9 kon\u010detin\u011b a tak\u00e9 vyprazd\u0148ov\u00e1n\u00ed \u017eiln\u00edho syst\u00e9mu po uvoln\u011bn\u00ed turniketu bude pomalej\u0161\u00ed. To se odraz\u00ed v men\u0161\u00edm po\u010d\u00e1te\u010dn\u00edm poklesu a n\u00e1sledn\u00e9m pomalej\u0161\u00edm vzestupu impedance.<br \/>\nS n\u00e1stupem ultrazvukov\u00fdch vy\u0161et\u0159ovac\u00edch metod ztratila IPG v diagnostice flebotromb\u00f3zy sv\u016fj v\u00fdznam.<\/li>\n<li><em style=\"text-align: justify;\"><\/em><em>D-dim\u00e9ry<\/em><br \/>\nP\u0159edstavuj\u00ed kone\u010dn\u00fd produkt degradace fibrinov\u00e9 m\u0159\u00ed\u017eky. Vznikaj\u00ed proteol\u00fdzou fibr\u00ednu p\u016fsoben\u00edm plazminu. Zv\u00fd\u0161en\u00e9 hladiny D-dim\u00e9r\u016f sv\u011bd\u010d\u00ed o aktivaci zevn\u00edho a vnit\u0159n\u00edho syst\u00e9mu koagulace a tak\u00e9 fibrinol\u00fdzy.<br \/>\nStupe\u0148 zv\u00fd\u0161en\u00ed D-dim\u00e9r\u016f odr\u00e1\u017e\u00ed rozsah tromb\u00f3zy, trv\u00e1n\u00ed p\u0159\u00edznak\u016f a pou\u017eit\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dby. <b>Vysok\u00e1 hladina D-dim\u00e9r\u016f <\/b>sv\u011bd\u010d\u00ed pro v\u011bt\u0161\u00ed rozsah tromb\u00f3zy, kr\u00e1tk\u00e9 trv\u00e1n\u00ed klinick\u00fdch p\u0159\u00edznak\u016f bez aplikace antikoagulancia. <b>N\u00edzk\u00e1\u00a0<\/b>hladina D-dim\u00e9r\u016f je naopak zn\u00e1mkou mal\u00e9ho rozsahu tromb\u00f3zy, dlouh\u00e9ho trv\u00e1n\u00ed klinick\u00fdch p\u0159\u00edznak\u016f a pod\u00e1n\u00ed antikoagulancia. D-dim\u00e9ry maj\u00ed vysokou negativn\u00ed prediktivn\u00ed hodnotu, jsou senzitivn\u00edm, ale nespecifick\u00fdm vy\u0161et\u0159en\u00edm, proto <b>se pou\u017e\u00edvaj\u00ed k vylou\u010den\u00ed tromboembolick\u00e9 nemoci<\/b>.<\/li>\n<\/ol>\n<\/li>\n<\/ul>\n<ul style=\"text-align: justify;\">\n<li><strong><strong>P\u0159\u00edm<\/strong><\/strong><strong>\u00e9 diagnostick\u00e9 metody<\/strong>\n<ol>\n<li>Rentgenov\u00e1 venografie (flebografie, digit\u00e1ln\u00ed\u00a0subtrak\u010dn\u00ed flebografie)<br \/>\nJej\u00edmi nev\u00fdhodami jsou invazivnost (kanylace podko\u017en\u00ed \u017e\u00edly na b\u00e9rci nebo na noze), cena, rizika spojen\u00e1 s intraven\u00f3zn\u00ed aplikac\u00ed jodov\u00e9 kontrastn\u00ed l\u00e1tky (lok\u00e1ln\u00ed dr\u00e1\u017ed\u011bn\u00ed, celkov\u00e1 alergick\u00e1 reakce, vznik irita\u010dn\u00ed tromboflebitidy nebo ren\u00e1ln\u00edho selh\u00e1n\u00ed), radia\u010dn\u00ed z\u00e1t\u011b\u017e a nepohodl\u00ed pro pacienta i l\u00e9ka\u0159e. Dnes se v\u011bt\u0161inou pou\u017e\u00edv\u00e1 v kombinaci s trombolytickou l\u00e9\u010dbou.Kontrastn\u00ed l\u00e1tka se p\u0159i flebografii aplikuje do \u017eiln\u00edho \u0159e\u010di\u0161t\u011b p\u0159\u00edmou punkc\u00ed \u017e\u00edly nebo kat\u00e9trem.<br \/>\nP\u0159\u00edmou punkc\u00ed a aplikac\u00ed kontrastn\u00ed l\u00e1tky jehlou do \u017eiln\u00edho syst\u00e9mu se vy\u0161et\u0159uje \u017eiln\u00ed syst\u00e9m horn\u00edch i doln\u00edch kon\u010detin.<br \/>\nHlubok\u00fd \u017eiln\u00ed syst\u00e9m <b>doln\u00edch kon\u010detin <\/b>se vy\u0161et\u0159uje dvoj\u00edm zp\u016fsobem, a to ascendentn\u00ed nebo descendentn\u00ed flebografi\u00ed. <b>Ascenden<\/b><strong>tn\u00ed flebografie<\/strong> se prov\u00e1d\u00ed aplikac\u00ed kontrastn\u00ed l\u00e1tky do oblasti\u00a0povrchov\u00fdch \u017eil palce nebo dorza nohy. Do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu se tok kontrastn\u00ed l\u00e1tky sm\u011bruje za\u0161krcen\u00edm povrchov\u00fdch \u017eil ve v\u00fd\u0161i talokrur\u00e1ln\u00edho kloubu. Je tak mo\u017en\u00e9 dob\u0159e zhodnotit pr\u016fchodnost hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu,homogenitu n\u00e1pln\u011b \u017eil i funkci jejich chlopenn\u00edho apar\u00e1tu a funkci perfor\u00e1tor\u016f. P\u0159i <strong>descendentn\u00ed<\/strong> flebografii se kontrastn\u00ed l\u00e1tka aplikuje\u00a0do femor\u00e1ln\u00ed \u017e\u00edly a sleduje se, zda je zadr\u017eov\u00e1na chlopn\u011bmi nebo prot\u00e9k\u00e1 retrogr\u00e1dn\u011b p\u0159es nedomykav\u00e9 chlopn\u011b.<br \/>\nPokud je pot\u0159eba zobrazit \u017eiln\u00ed syst\u00e9m ve v\u011bt\u0161\u00ed vzd\u00e1lenosti od obvykl\u00fdch m\u00edst punkce \u017eiln\u00edho syst\u00e9mu, prov\u00e1d\u00ed se flebografie katetriza\u010dn\u011b Seldigerovou technikou. P\u0159\u00edstupov\u00fdm m\u00edstem pro flebografii je v. femoralis, v. jugularis interna nebo v. mediana cubiti. Touto technikou se vy\u0161et\u0159uj\u00ed ky\u010deln\u00ed \u017e\u00edly, horn\u00ed a doln\u00ed dut\u00e1 \u017e\u00edla (kavografie) a jejich p\u0159\u00edtoky.<br \/>\n\u017diln\u00ed syst\u00e9m <b>horn\u00edch kon\u010detin <\/b>se vy\u0161et\u0159uje vpichem do \u017e\u00edly na dorzu ruky, p\u0159\u00edpadn\u011b vpichem do co nejperifern\u011bj\u0161\u00ed povrchov\u00e9 \u017e\u00edly. Je mo\u017en\u00e9 zhodnotit jak hlubok\u00fd, tak povrchov\u00fd \u017eiln\u00ed syst\u00e9m horn\u00ed kon\u010detiny v\u010detn\u011b centr\u00e1ln\u00edho \u017eiln\u00edho v\u00fdtokov\u00e9ho traktu.<\/li>\n<li><em><em><\/em><\/em><em><strong>Radioizotopov\u00e9 vy\u0161et\u0159ovac\u00ed metody<\/strong><br \/>\n<em><strong>Radioizotopy<\/strong> se v diagnostice flebotromb\u00f3zy\u00a0pou\u017e\u00edvaj\u00ed dv\u011bma zp\u016fsoby. Prvn\u00edm je <strong>radioizotopov\u00e1<\/strong> venografie, obdoba rentgenov\u00e9 venografie, kdy se do \u017e\u00edly na noze aplikuje makroagreg\u00e1t albuminu (MAA) zna\u010den\u00fd techneciem. Druh\u00fdm zp\u016fsobem vyu\u017eit\u00ed radioizotop\u016f je p\u0159\u00edm\u00e1 vizualizace trombu zna\u010den\u00fdmi trombocyty nebo fibrinogenem. Trombocyty zna\u010den\u00e9 techneciem\u00a099m maj\u00ed 80\u201390% pozitivn\u00ed prediktivn\u00ed hodnotu.<\/em><\/em><\/li>\n<li><em><em><\/em><\/em><em><strong>Ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed<\/strong><br \/>\n<em>Od poloviny 80. let 20. stolet\u00ed se v diagnostice flebotromb\u00f3zy za\u010dala pou\u017e\u00edvat ultrasonografie (<b>tzv. kompresn\u00ed ultrazvukov\u00e1 metoda<\/b>). Je to metoda s <b>vysokou senzitivitou a specificitou.<\/b><\/em><\/em><\/li>\n<li><em><em><b><\/b><\/em><strong>CT flebografie<\/strong><\/em><br \/>\nVe srovn\u00e1n\u00ed s magnetickou rezonanc\u00ed jde o rychlej\u0161\u00ed a levn\u011bj\u0161\u00ed vy\u0161et\u0159en\u00ed. Jeho v\u00fdhodou je tak\u00e9 sou\u010dasn\u00e9 zobrazen\u00ed patologick\u00fdch proces\u016f(kalcifikovan\u00e9 granulomat\u00f3zn\u00ed lymfatick\u00e9 uzliny) nebo metast\u00e1z komprimuj\u00edc\u00edch posti\u017een\u00e9 ky\u010deln\u00ed \u017e\u00edly. CT flebografii lze s v\u00fdhodou kombinovat s CT plicn\u00ed angiografi\u00ed k vylou\u010den\u00ed plicn\u00ed embolie. Hlavn\u00edmi nev\u00fdhodami jsou radia\u010dn\u00ed z\u00e1t\u011b\u017e a aplikace jodov\u00e9 kontrastn\u00ed l\u00e1tky (alergie na j\u00f3d, ren\u00e1ln\u00ed insuficience).<\/li>\n<li><strong>Magnetick\u00e1 rezonance (MRI \u2013 magnetic resonance imaging) a magnetick\u00e1 rezonan\u010dn\u00ed\u00a0venografie (MRV \u2013 magnetic resonance venography)<\/strong><br \/>\nMR je stejn\u011b jako CT vyu\u017e\u00edv\u00e1na k diagnostick\u00e9mu zobrazov\u00e1n\u00ed p\u0159edev\u0161\u00edm centr\u00e1ln\u00edch \u017eil,port\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b a u onemocn\u011bn\u00ed \u017eiln\u00edho syst\u00e9mu CNS. Prim\u00e1rn\u00ed indikac\u00ed je proto vy\u0161et\u0159en\u00ed p\u00e1nevn\u00edho \u017eiln\u00edho \u0159e\u010di\u0161t\u011b, kde je MR senzitivn\u011bj\u0161\u00edm vy\u0161et\u0159en\u00edm ne\u017e ultrazvuk a diagnostika tromb\u00f3zy mozkov\u00fdch \u017eiln\u00edch splav\u016f. MR je tak\u00e9 preferov\u00e1na, pokud chceme zjistit p\u0159esn\u00fd rozsah \u017eiln\u00edho trombotick\u00e9ho posti\u017een\u00ed. Ve srovn\u00e1n\u00ed s CT vy\u0161et\u0159en\u00edm nen\u00ed MR zat\u00ed\u017eena artefakty vyvolan\u00fdmi krevn\u00edm proud\u011bn\u00edm.<\/li>\n<\/ol>\n<\/li>\n<\/ul>\n<h6>DIAGNOSTIKA PERIFERN\u00cdCH \u017dILN\u00cdCH MALFORMAC\u00cd<\/h6>\n<p style=\"text-align: justify;\">U vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed je z hlediska n\u00e1sledn\u00e9 l\u00e9\u010dby z\u00e1sadn\u00ed rozli\u0161it n\u00edzkopr\u016ftokov\u00e9 malformace od vysokopr\u016ftokov\u00fdch (s arteri\u00e1ln\u00ed slo\u017ekou). D\u00e1le je pot\u0159eba ur\u010dit lokalizaci, rozsah a vztah k okoln\u00edm struktur\u00e1m a org\u00e1n\u016fm.<\/p>\n<p style=\"text-align: justify;\">Vy\u0161et\u0159en\u00ed <b>dopplerovskou ultrasonografi\u00ed <\/b>je levn\u00e9 a dostupn\u00e9. Dob\u0159e rozli\u0161\u00ed n\u00edzkopr\u016ftokov\u00e9 a vysokopr\u016ftokov\u00e9 l\u00e9ze. <b>Magnetick\u00e1 rezonance <\/b>je z\u00e1kladn\u00ed vy\u0161et\u0159ovac\u00ed metodou, kter\u00e1 rozli\u0161\u00ed n\u00edzkopr\u016ftokov\u00e9 malformace od vysokopr\u016ftokov\u00fdch a velmi dob\u0159e zobraz\u00ed lokalizaci a rozsah l\u00e9ze, jej\u00ed vztah k okoln\u00edm struktur\u00e1m a org\u00e1n\u016fm (Fayad, 2006, Yakes, 2008). Digit\u00e1ln\u00ed subtrak\u010dn\u00ed <b>angiografie <\/b>je dnes sou\u010d\u00e1st\u00ed l\u00e9\u010debn\u00fdch v\u00fdkon\u016f.<\/p>\n<p style=\"text-align: justify;\">N\u00edzkopr\u016ftokov\u00e9 <b>\u017eiln\u00ed malformace <\/b>na <b>prost\u00e9m sn\u00edmku <\/b>tvo\u0159\u00ed m\u011bkkotk\u00e1\u0148ovou expanzi p\u0159\u00edpadn\u011b s flebolity a abnormalitami skeletu. Flebolity jsou pro \u017eiln\u00ed malformace patognomonick\u00e9 (Dubois, 2001).<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\" scope=\"col\"><span style=\"color: #ffffff;\">Tabulka 1<\/span><br \/>\n<span style=\"line-height: 19px; color: #ffffff;\">P\u0159ehled pou\u017e\u00edvan\u00fdch venofarmak<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\" scope=\"col\"><strong>1. VENOFARMAKA NA B\u00c1ZI P\u0158\u00cdRODN\u00cdCH L\u00c1TEK<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" width=\"50%\"><strong>\u00da\u010dinn\u00e1 l\u00e1tka<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>N\u00e1zev l\u00e9ku\u00a0<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Aescin \u2013 v\u00fdta\u017eek s ka\u0161tanu ko\u0148sk\u00e9ho \u2013 j\u00edrovec ma\u010fal (Aesculus hippocastanum)<\/td>\n<td>Aescin-Polfa tbl. 20 mg Aescin-Teva tbl. 20 mg Yellon cps. 20 mg<\/td>\n<\/tr>\n<tr>\n<td>Aescin + anthokyanosidy z bor\u016fvek + v\u00fdta\u017eek z listnatce bodlinat\u00e9ho (Ruscus aculeatus) + v\u00fdta\u017eek z gotu kola (Centella asiatica)<\/td>\n<td>Varixinal tbl.<\/td>\n<\/tr>\n<tr>\n<td>Flavonoidy (biofl avonoidy, bioflavonoidn\u00ed glykosidy, vitamin P)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>Rutin \u2013 v\u00fdta\u017eek z brazilsk\u00e9 bobokv\u011bt\u00e9 rostliny (Dimorphandra mollis)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>Rutin (+ vitamin C)<\/td>\n<td>Ascorutin tbl.<\/td>\n<\/tr>\n<tr>\n<td>Rutin (+ aescin + dihydroergokristin)<\/td>\n<td>Anavenol tbl.<\/td>\n<\/tr>\n<tr>\n<td>Rutin (+ hesperidin + vitamin C)<\/td>\n<td>Cyklo 3 Fort<\/td>\n<\/tr>\n<tr>\n<td>Kvercetin \u2013 v\u00fdta\u017eek z \u010derven\u00fdch list\u016f vinn\u00e9 r\u00e9vy (Vitus viniferae)<\/td>\n<td>Antistax cps. 180 mg<\/td>\n<\/tr>\n<tr>\n<td>Hesperidin \u2013 v\u00fdta\u017eek z oplod\u00ed pomeran\u010d\u016f Hesperidin (+ diosmin = dehydrohesperidin \u2013 syntetick\u00fd deriv\u00e1t hesperidinu)<\/td>\n<td>Detralex tbl<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\"><strong>2. VENOFARMAKA NA B\u00c1ZI POLYSYNTETICK\u00ddCH L\u00c1TEK<\/strong><\/td>\n<\/tr>\n<tr>\n<td>\u00a0Rutosidy (vznikaj\u00ed chemickou modifikac\u00ed p\u0159\u00edrodn\u00edho rutinu)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>\u00a0Troxerutin = oxerutin (hydroxyethylrutosid)<\/td>\n<td>Cilkanol cps. 300 mg Venoruton cps. 300 mg Venoruton F cps. 500 mg<\/td>\n<\/tr>\n<tr>\n<td>\u00a0Troxerutin (+ heptaminol + ginkgo biloba)<\/td>\n<td>Ginkor Fort cps.<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\"><strong>3. VENOFARMAKA NA B\u00c1ZI SYNTETICK\u00ddCH L\u00c1TEK<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Dobesil\u00e1t v\u00e1penat\u00fd<br \/>\n<span style=\"line-height: 19px;\">(s\u016fl kyseliny dihydroxybenzensulfonov\u00e9)<\/span><\/td>\n<td>Doxium tbl. 500 mg<br \/>\n<span style=\"line-height: 19px;\">Danium tbl. 250 mg<br \/>\n<\/span><span style=\"line-height: 19px;\">Dobica tbl. 250 mg<\/span><\/td>\n<\/tr>\n<tr>\n<td>\u00a0Heptaminol (+ troxerutin + ginkgo biloba)<\/td>\n<td>Ginkor Fort cps.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h3><!--nextpage--><\/h3>\n<h3>10.4 L\u00e9\u010dba \u017eiln\u00edch onemocn\u011bn\u00ed<\/h3>\n<h4>10.4.1 Konzervativn\u00ed l\u00e9\u010dba \u2013 venofarmaka<\/h4>\n<p style=\"text-align: justify;\">Venofarmaka jsou p\u0159\u00edrodn\u00ed, polosyntetick\u00e9 nebo syntetick\u00e9 l\u00e1tky pou\u017e\u00edvan\u00e9 v l\u00e9\u010db\u011b \u017eiln\u00edch onemocn\u011bn\u00ed (tab. 1 na str. 106). Jejich l\u00e9\u010debn\u00fd \u00fa\u010dinek je zalo\u017een\u00fd na protiz\u00e1n\u011btliv\u00e9m, antioxida\u010dn\u00edm, antiedemat\u00f3zn\u00edm a proteolytick\u00e9m p\u016fsoben\u00ed ve tk\u00e1n\u00edch, na sni\u017eov\u00e1n\u00ed propustnosti st\u011bny kapil\u00e1r a na zvy\u0161ov\u00e1n\u00ed tonu st\u011bn \u017eil a lymfatick\u00fdch c\u00e9v. Od farmakologick\u00e9 l\u00e9\u010dby lze o\u010dek\u00e1vat \u00falevu od subjektivn\u00edch pot\u00ed\u017e\u00ed spojen\u00fdch s \u017eiln\u00ed insuficienc\u00ed (pocity nap\u011bt\u00ed, tlaku a bolesti) a \u00fastup otok\u016f doln\u00edch kon\u010detin. Venofarmaka nep\u0159edstavuj\u00ed prevenci rozvoje varix\u016f, trofick\u00fdch zm\u011bn k\u016f\u017ee a podko\u017e\u00ed nebo prevenci \u017eiln\u00ed tromb\u00f3zy, povrchov\u00e9 nebo hlubok\u00e9.<\/p>\n<h4 style=\"text-align: justify;\">10.4.2 Antikoagula\u010dn\u00ed l\u00e9\u010dba<\/h4>\n<p style=\"text-align: justify;\">Antikoagula\u010dn\u00ed l\u00e9\u010dba je od \u010dty\u0159ic\u00e1t\u00fdch let 20. stolet\u00ed prim\u00e1rn\u00ed l\u00e9\u010dbou tromboembolick\u00e9 nemoci a svou v\u00fdznamnou roli od devades\u00e1t\u00fdch let 20. stolet\u00ed hraje tak\u00e9 ve farmakoterapii tromboflebitidy. U tromboembolick\u00e9 nemoci p\u0159i v\u010dasn\u00e9m nasazen\u00ed sni\u017euje riziko plicn\u00ed embolie, br\u00e1n\u00ed \u0161\u00ed\u0159en\u00ed tromb\u00f3zy a sni\u017euje pravd\u011bpodobnost jej\u00ed recidivy. Antikoagulancia jsou pod\u00e1v\u00e1na celkov\u011b intraven\u00f3zn\u011b, subkut\u00e1nn\u011b nebo peror\u00e1ln\u011b. V sou\u010dasn\u00e9 klinick\u00e9 praxi se v antikoagula\u010dn\u00ed l\u00e9\u010db\u011b pou\u017e\u00edvaj\u00ed hepariny, antagonist\u00e9 vitaminu K (peror\u00e1ln\u00ed antikoagulancia), p\u0159\u00edm\u00e9 inhibitory trombinu (syntetick\u00e9 deriv\u00e1ty hirudinu\/lepirudin, bivalirudin, desirudin\/, argatroban a gatrany) a p\u0159\u00edm\u00e9 inhibitory aktivovan\u00e9ho faktoru X (rivaroxaban, apixaban, otamixaban).<\/p>\n<h6 style=\"text-align: justify;\">HEPARINY<\/h6>\n<p style=\"text-align: justify;\">Heparin je sm\u011bs polysacharid\u016f, p\u0159\u00edrodn\u00ed antikoagula\u010dn\u00ed l\u00e1tka, produkov\u00e1na n\u011bkter\u00fdmi \u017eivo\u010di\u0161n\u00fdmi tk\u00e1n\u011bmi, b\u00edl\u00fdmi krvinkami (bazofiln\u00ed leukocyty) a mastocyty (\u017e\u00edrn\u00e9 bu\u0148ky, heparinocyty). Nefrakcionovan\u00fd heparin obsahuje sacharidov\u00e9 polymery (polysacharidy) s molekulovou hmotnost\u00ed 5000\u201335 000 dalton\u016f (pr\u016fm\u011brn\u011b 13 000\u201320 000 D). Funguje jako nep\u0159\u00edm\u00fd neselektivn\u00ed inhibitor trombinu a aktivovan\u00e9ho faktoru X. L\u00e9\u010dba je zahajov\u00e1na \u00favodn\u00ed nitro\u017eiln\u00ed aplikac\u00ed bolusu (5000\u201310 000 j. ) a pak n\u00e1sleduje kontinu\u00e1ln\u00ed pod\u00e1v\u00e1n\u00ed, nej\u010dast\u011bji v d\u00e1vce 20 000\u201340 000 j. \/24 hod. infuzn\u00ed pumpou nebo injektorem. \u00da\u010dinnost l\u00e9\u010dby je kontrolov\u00e1na stanoven\u00edm aPTT (prodlou\u017een\u00ed aPTT 1,5\u20132kr\u00e1t proti kontrole). Sou\u010dasn\u011b s pod\u00e1v\u00e1n\u00edm heparinu zahajujeme peror\u00e1ln\u00ed antikoagula\u010dn\u00ed l\u00e9\u010dbu warfarinem. Heparin je vysazen p\u0159i dosa\u017een\u00ed INR 2\u20133 ve dvou po sob\u011b n\u00e1sleduj\u00edc\u00edch dnech. Antidotem heparinu je protamin sulf\u00e1t, kter\u00fd je pod\u00e1v\u00e1n jen p\u0159i masivn\u00edm krv\u00e1cen\u00ed v d\u00e1vce 1 mg na 100 j. heparinu aplikovan\u00fdch v posledn\u00edch 8\u201312 hodin\u00e1ch. P\u0159i l\u00e9\u010db\u011b heparinem se mohou asi u 1% nemocn\u00fdch vytvo\u0159it protil\u00e1tky proti desti\u010dk\u00e1m s n\u00e1sledn\u00fdm rozvojem trombocytopenie. Po 2\u20137 dnech l\u00e9\u010dby se proto doporu\u010duje kontrola po\u010dtu trombocyt\u016f a p\u0159i jejich poklesu pod 100.109\/l je nutn\u00e9 heparin zam\u011bnit za peror\u00e1ln\u00ed antikoagulancia nebo jin\u00e9 inhibitory trombinu. V sou\u010dasnosti je nefrakcionovan\u00fd heparin nahrazov\u00e1n n\u00edzkomolekul\u00e1rn\u00edmi hepariny (LMWH). N\u00edzkomolekul\u00e1rn\u00ed hepariny (LMWH, Low Molecular Weight Heparins) jsou heparinov\u00e9 frakce (produkty enzymov\u00e9ho \u0161t\u011bpen\u00ed standardn\u00edho heparinu) o pr\u016fm\u011brn\u00e9 molekulov\u00e9 hmotnosti 3500\u20135000 dalton\u016f, kter\u00e9 inaktivuj\u00ed zejm\u00e9na faktor Xa a jen m\u00e1lo trombin (f. II). Lze je pod\u00e1vat ve fixn\u00ed d\u00e1vce podle t\u011blesn\u00e9 hmotnosti, v\u011bt\u0161inou bez laboratorn\u00edho monitorov\u00e1n\u00ed. Jsou \u00fa\u010dinn\u011bj\u0161\u00ed a bezpe\u010dn\u011bj\u0161\u00ed ne\u017e nefrakcionovan\u00fd heparin, pod\u00e1van\u00fd podle aktu\u00e1ln\u00edch hodnot aPTT. Mezi v\u00fdhody LMWH pat\u0159\u00ed ni\u017e\u0161\u00ed riziko krv\u00e1cen\u00ed, men\u0161\u00ed protidesti\u010dkov\u00e1 aktivita (souvis\u00ed s ni\u017e\u0161\u00edm rizikem krv\u00e1cen\u00ed) (tab. 2 a 3). Rozd\u00edly mezi jednotliv\u00fdmi LMWH spo\u010d\u00edvaj\u00ed p\u0159edev\u0161\u00edm v r\u016fzn\u00e9 molekulov\u00e9 hmotnosti a z toho vypl\u00fdvaj\u00edc\u00edch rozd\u00edl\u016f ve farmakodynamice a farmakokinetice. Terapeutick\u00e9 d\u00e1vkov\u00e1n\u00ed je u ka\u017ed\u00e9ho prepar\u00e1tu r\u016fzn\u00e9 a z\u00e1vis\u00ed na hmotnosti nemocn\u00e9ho (tab. 4). \u00daprava d\u00e1vkov\u00e1n\u00ed a monitorov\u00e1n\u00ed plazmatick\u00e9 antiXa aktivity jsou pot\u0159ebn\u00e9 u pacient\u016f s t\u011blesnou hmotnost\u00ed pod 40 kg nebo nad 150 kg, u t\u011bhotn\u00fdch \u017een (tab. 5) a nemocn\u00fdch s ren\u00e1ln\u00edm selh\u00e1n\u00edm. Pro sekund\u00e1rn\u00ed profylaxi tromboembolick\u00e9 nemoci u pacient\u016f s n\u00e1dorem v jak\u00e9mkoliv stadiu onemocn\u011bn\u00ed je dlouhodob\u00e9 pod\u00e1v\u00e1n\u00ed fixn\u00ed d\u00e1vky LMWH efektivn\u011bj\u0161\u00ed a bezpe\u010dn\u011bj\u0161\u00ed ne\u017e pod\u00e1v\u00e1n\u00ed warfarinu. Optim\u00e1ln\u00ed d\u00e9lka l\u00e9\u010dby zat\u00edm nen\u00ed jasn\u00e1, ale pacienti s aktivn\u00edm n\u00e1dorem jsou pacienti se z\u00edskanou trombofili\u00ed, a proto je u nich v\u011bt\u0161inou doporu\u010dov\u00e1na trval\u00e1 l\u00e9\u010dba.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" scope=\"col\">Tabulka 2<br \/>\nHepariny<\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Kontraindikace \u2013 p\u0159ecitliv\u011blost na heparin, krv\u00e1civ\u00e9 stavy (krom\u011b diseminovan\u00e9 intravaskul\u00e1rn\u00ed koagulace), aktivn\u00ed v\u0159edov\u00e1 choroba gastroduoden\u00e1ln\u00ed, trombocytopatie, t\u011b\u017ek\u00e1 arteri\u00e1ln\u00ed hypertenze, t\u011b\u017ek\u00e9 po\u0161kozen\u00ed jater a ledvin, disekuj\u00edc\u00ed aneuryzma aorty<\/li>\n<li>Ne\u017e\u00e1douc\u00ed \u00fa\u010dinky \u2013 trombocytopenie, alergick\u00e9 reakce, krv\u00e1cen\u00ed, p\u0159echodn\u00e1 alopecie, zv\u00fd\u0161en\u00ed jatern\u00edch transamin\u00e1z, hyperlipidemie, osteopor\u00f3za<\/li>\n<li>L\u00e9kov\u00e9 interakce \u2013 \u00fa\u010dinek heparinu zvy\u0161uj\u00ed peror\u00e1ln\u00ed antikoagulancia a l\u00e9\u010diva ovliv\u0148uj\u00edc\u00ed agregaci trombocyt\u016f, \u00fa\u010dinek heparinu sni\u017euj\u00ed antihistaminika, kardioglykosidy a tetracyklinov\u00e1 antibiotika<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" scope=\"col\">Tabulka 3<br \/>\nVlastnosti n\u00edzkomolekul\u00e1rn\u00edch heparin\u016f (LMWH)<\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Kontraindikace \u2013 p\u0159ecitliv\u011blost na heparin, krv\u00e1civ\u00e9 stavy (krom\u011b diseminovan\u00e9 intravaskul\u00e1rn\u00ed koagulace), aktivn\u00ed v\u0159edov\u00e1 choroba gastroduoden\u00e1ln\u00ed, trombocytopatie, t\u011b\u017ek\u00e1 arteri\u00e1ln\u00ed hypertenze, t\u011b\u017ek\u00e9 po\u0161kozen\u00ed jater a ledvin, disekuj\u00edc\u00ed aneuryzma aorty<\/li>\n<li>Ne\u017e\u00e1douc\u00ed \u00fa\u010dinky \u2013 trombocytopenie, alergick\u00e9 reakce, krv\u00e1cen\u00ed, p\u0159echodn\u00e1 alopecie, zv\u00fd\u0161en\u00ed jatern\u00edch transamin\u00e1z, hyperlipidemie, osteopor\u00f3za<\/li>\n<li>L\u00e9kov\u00e9 interakce \u2013 \u00fa\u010dinek heparinu zvy\u0161uj\u00ed peror\u00e1ln\u00ed antikoagulancia a l\u00e9\u010diva ovliv\u0148uj\u00edc\u00ed agregaci trombocyt\u016f, \u00fa\u010dinek heparinu sni\u017euj\u00ed antihistaminika, kardioglykosidy a tetracyklinov\u00e1 antibiotika<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"3\" scope=\"col\">Tabulka 4<br \/>\nD\u00e1vkov\u00e1n\u00ed nej\u010dast\u011bji pou\u017e\u00edvan\u00fdch LMWH v \u010cR<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" width=\"33%\"><strong>\u00da\u010dinn\u00e1 l\u00e1tka (p\u0159\u00edpravek)<\/strong><\/td>\n<td style=\"text-align: center;\" width=\"33%\"><strong>D\u00e1vkov\u00e1n\u00ed (anti-Xa aktivita)<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>D\u00e1vkov\u00e1n\u00ed (mg nebo ml\/kg)<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Enoxaparin (Clexane)<\/td>\n<td>100 IU\/kg 2\u00d7 denn\u011b s.c.<\/td>\n<td>1 mg\/kg 2\u00d7 denn\u011b s.c.<\/td>\n<\/tr>\n<tr>\n<td>Enoxaparin (Clexane Forte)<\/td>\n<td>150 IU\/kg 1\u00d7 denn\u011b s.c.<\/td>\n<td>1,5 mg\/kg 1\u00d7 denn\u011b s.c.<\/td>\n<\/tr>\n<tr>\n<td>Nadroparin (Fraxiparine)<\/td>\n<td>95 IU\/kg 2\u00d7 denn\u011b s.c.<\/td>\n<td>0,1 ml\/10 kg 2\u00d7 denn\u011b s.c.<\/td>\n<\/tr>\n<tr>\n<td>Nadroparin (Fraxiparine Forte)<\/td>\n<td>190 IU\/kg 1\u00d7 denn\u011b s.c.<\/td>\n<td>0,1 ml\/10 kg 1\u00d7 denn\u011b s.c.<\/td>\n<\/tr>\n<tr>\n<td>Dalteparin (Fragmin)<\/td>\n<td>100\u2013120 IU\/kg 2\u00d7 denn\u011b s.c.<\/td>\n<td>0,1 ml\/10 kg 2\u00d7 denn\u011b s.c.<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"3\"><em>(Broul\u00edkov\u00e1, 2008)<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"5\" scope=\"col\">Tabulka 5<br \/>\nDoporu\u010den\u00e9 d\u00e1vkov\u00e1n\u00ed LMWH u t\u011bhotn\u00fdch \u017een podle t\u011blesn\u00e9 hmotnosti a rizika TEN<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" width=\"20%\"><strong>LMWH<\/strong><\/td>\n<td style=\"text-align: center;\" colspan=\"4\"><strong>T\u011blesn\u00e1 hmotnost<\/strong><\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td style=\"text-align: center;\" width=\"20%\"><em>pod 50 kg<\/em><\/td>\n<td style=\"text-align: center;\" width=\"20%\"><em>50\u201390 kg<\/em><\/td>\n<td style=\"text-align: center;\" width=\"20%\"><em>nad 90 kg<\/em><\/td>\n<td style=\"text-align: center;\" width=\"20%\"><em>velmi vysok\u00e9 riziko TEN<\/em><\/td>\n<\/tr>\n<tr>\n<td>Enoxaparin<\/td>\n<td>20 mg\/den<\/td>\n<td>40 mg\/den<\/td>\n<td>40 mg\/12 hod.<\/td>\n<td>0,5\u20131,0 mg\/kg\/12 hod.<\/td>\n<\/tr>\n<tr>\n<td>Dalteparin<\/td>\n<td>2500 U\/den<\/td>\n<td>5000 U\/den<\/td>\n<td>5000 U\/12 hod<\/td>\n<td>0\u2013100 U\/kg\/12 hod.<\/td>\n<\/tr>\n<tr>\n<td>Tinzaparin<\/td>\n<td>3500 U\/den<\/td>\n<td>4500 U\/den<\/td>\n<td>500 U\/12 hod.<\/td>\n<td>4500 U\/12 hod.<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"5\"><em>(Marik, 2008)<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h6>ANTAGONIST\u00c9 VITAMINU K<br \/>\n(PEROR\u00c1LN\u00cd ANTIKOAGULANCIA)<\/h6>\n<p style=\"text-align: justify;\">Existuj\u00ed dva typy antagonist\u016f vitaminu K, kumariny (deriv\u00e1ty dikumarolu) a indanediony. P\u016fsob\u00ed v j\u00e1trech jako antagonist\u00e9 vitaminu K, kde antagonizuj\u00ed synt\u00e9zu koagula\u010dn\u00edch faktor\u016f z\u00e1visl\u00fdch na vitaminu K (II, VII, IX, X). Ji\u017e vytvo\u0159en\u00e9 koagula\u010dn\u00ed faktory nejsou ovlivn\u011bny, proto antikoagula\u010dn\u00ed \u00fa\u010dinek pln\u011b nastupuje s latenc\u00ed, kter\u00e1 je z\u00e1visl\u00e1 na rychlosti p\u0159irozen\u00e9ho z\u00e1niku t\u011bchto faktor\u016f (u warfarinu za 4\u20135 dn\u016f). Deriv\u00e1ty dikumarolu maj\u00ed \u00fazk\u00e9 terapeutick\u00e9 rozmez\u00ed a \u010detn\u00e9 l\u00e9kov\u00e9 i dietn\u00ed interakce. P\u0159i jejich l\u00e9\u010db\u011b jsou nutn\u00e1 dietn\u00ed opat\u0159en\u00ed a opakovan\u00e9 monitorov\u00e1n\u00ed protrombinov\u00e9ho \u010dasu (Quick\u016fv test) nebo l\u00e9pe INR (International Normalized Ratio \u2013 pom\u011br protrombinov\u00e9ho \u010dasu pacienta ke kontroln\u00edmu norm\u00e1lu pou\u017e\u00edvaj\u00edc\u00edmu mezin\u00e1rodn\u00ed referen\u010dn\u00ed prepar\u00e1t). C\u00edlem pod\u00e1v\u00e1n\u00ed warfarinu je INR mezi 2 a 3.<\/p>\n<p style=\"text-align: justify;\">Peror\u00e1ln\u00ed antikoagulancia jsou absolutn\u011b kontraindikov\u00e1na u t\u011b\u017ek\u00e9 nekontrolovan\u00e9 arteri\u00e1ln\u00ed hypertenze, netromboembolick\u00e9 CMP, u aktivn\u00ed peptick\u00e9 ulcerace, p\u0159i t\u011b\u017ek\u00e9 jatern\u00ed nebo ledvinov\u00e9 nedostate\u010dnosti, u preexistuj\u00edc\u00edch defekt\u016f hemost\u00e1zy a u nespolupracuj\u00edc\u00edch pacient\u016f. Pro svou teratogenitu a nebezpe\u010d\u00ed fet\u00e1ln\u00edho krv\u00e1cen\u00ed nesm\u011bj\u00ed b\u00fdt pou\u017eity tak\u00e9 v t\u011bhotenstv\u00ed.<\/p>\n<h6>P\u0158\u00cdM\u00c9 INHIBITORY TROMBINU<\/h6>\n<ol>\n<li>\n<div style=\"text-align: justify;\"><strong>Syntetick\u00e9 deriv\u00e1ty hirudinu (lepirudin, desirudin, bivalirudin)<\/strong><br \/>\nExtrakt se slin pijavky l\u00e9ka\u0159sk\u00e9 (Hirudo medicinalis) br\u00e1n\u00ed sr\u00e1\u017een\u00ed krve d\u00edky peptidu hirudinu, p\u0159\u00edm\u00e9mu ireverzibiln\u00edmu inhibitoru trombinu. Hirudin s\u00e1m nemohl b\u00fdt v hum\u00e1nn\u00ed medic\u00edn\u011b pro svou toxicitu nikdy vyu\u017eit\u00fd. Ke slovu p\u0159i\u0161ly a\u017e jeho syntetick\u00e9 deriv\u00e1ty lepirudin, bivalirudin, desirudin, jejich\u017e p\u016fsoben\u00ed m\u016f\u017ee b\u00fdt monitorov\u00e1no pomoc\u00ed aPTT. Jsou vylu\u010dov\u00e1ny ledvinami, proto je nutn\u00e1 opatrnost p\u0159i ren\u00e1ln\u00ed insuficienci. Lepirudin (Refludan) se pou\u017e\u00edv\u00e1 pro l\u00e9\u010dbu HIT a spolu s kyselinou acetylsalicylovou u akutn\u00edho koron\u00e1rn\u00edho syndromu. Desirudin (Revasc) ke kr\u00e1tkodob\u00e9 tromboprofylaxi p\u0159i tot\u00e1ln\u00ed endoprot\u00e9ze ky\u010deln\u00edho kloub\u016f ve 20 evropsk\u00fdch zem\u00edch a bivalirudin (syntetick\u00fd polypeptidov\u00fd analog hirudinu) je schv\u00e1len\u00fd FDA (US Food and Drug Administration) u pacient\u016f po PTCA pro akutn\u00ed koron\u00e1rn\u00ed syndrom.<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\"><strong>Argatroban<\/strong><br \/>\nTento n\u00edzkomolekul\u00e1rn\u00ed deriv\u00e1t argininu se nekovalentn\u011b v\u00e1\u017ee na aktivn\u00ed m\u00edsto trombinu, s n\u00edm\u017e vytv\u00e1\u0159\u00ed reverzibiln\u00ed komplex. Plazmatick\u00fd polo\u010das argatrobanu je 45 minut a l\u00e9k je metabolizov\u00e1n j\u00e1try, proto mus\u00ed b\u00fdt u onemocn\u011bn\u00ed jater pod\u00e1v\u00e1n s velkou opatrnost\u00ed. Naopak bezpe\u010dn\u011b ho lze pou\u017e\u00edt u ren\u00e1ln\u00ed insuficience. Indikac\u00ed argatrobanu je HIT.<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\"><strong>Gatrany<\/strong><br \/>\nZ t\u00e9to skupiny p\u0159\u00edm\u00fdch reverzibiln\u00edch inhibitor\u016f trombinu se v b\u011b\u017en\u00e9 klinick\u00e9 praxi zat\u00edm pou\u017e\u00edv\u00e1 dabigatran etexil\u00e1t (Pradaxa).<\/div>\n<\/li>\n<\/ol>\n<h6 style=\"text-align: justify;\">P\u0158\u00cdM\u00c9 INHIBITORY AKTIVOVAN\u00c9HO FAKTORU X (XABANY)<\/h6>\n<p style=\"text-align: justify;\">Aplikuj\u00ed se bu\u010f peror\u00e1ln\u011b (rivaroxaban, apixaban) nebo parenter\u00e1ln\u011b (otamixaban). Jejich p\u0159ednost\u00ed je vysok\u00e1 selektivita pro aktivovan\u00fd faktor X (f. Xa) a pod\u00e1v\u00e1n\u00ed jednou nebo dvakr\u00e1t denn\u011b. Dal\u0161\u00ed v\u00fdhodou je du\u00e1ln\u00ed vylu\u010dov\u00e1n\u00ed mo\u010d\u00ed i stolic\u00ed. Rivaroxaban (Xarelto) v d\u00e1vkov\u00e9m rozmez\u00ed 5\u201320 mg denn\u011b prok\u00e1zal v profylaxi tromboembolick\u00e9 nemoci u ortopedick\u00fdch pacient\u016f stejn\u00fd terapeutick\u00fd a krv\u00e1civ\u00fd potenci\u00e1l jako enoxaparin.<\/p>\n<h6 style=\"text-align: justify;\">HEPARINEM VYVOLAN\u00c1 TROMBOCY TOPENIE\u00a0(HIT = HEPARININDUCED THROMBOCY TOPENIA)<\/h6>\n<p style=\"text-align: justify;\">Heparinem vyvolan\u00e1 trombocytopenie (HIT) je z\u00e1va\u017en\u00fdm ne\u017e\u00e1douc\u00edm \u00fa\u010dinkem heparinu s velk\u00fdm rizikem vzniku trombotick\u00fdch komplikac\u00ed. P\u0159\u00ed\u010dinou je tvorba autoprotil\u00e1tek proti heparinov\u00e9 molekule, kter\u00e1 vede k aktivaci trombocyt\u016f a tvorb\u011b trombinu. P\u0159esto\u017ee se protil\u00e1tky proti heparinu tvo\u0159\u00ed u 10\u201320% pacient\u016f l\u00e9\u010den\u00fdch heparinem, u v\u011bt\u0161iny z nich nikdy nevznikne HIT. Protil\u00e1tky jsou p\u0159echodn\u00e9 a z cirkulace vymiz\u00ed pr\u016fm\u011brn\u011b b\u011bhem 85 dn\u016f po ukon\u010den\u00ed l\u00e9\u010dby. Diagn\u00f3za spo\u010d\u00edv\u00e1 na klinick\u00fdch a laboratorn\u00edch n\u00e1lezech. Klinicky asi v 50% p\u0159\u00edpad\u016f vznik\u00e1 nov\u00e1 akutn\u00ed \u017eiln\u00ed tromb\u00f3za. Arteri\u00e1ln\u00ed tromb\u00f3za je m\u00e9n\u011b \u010dast\u00e1 (uz\u00e1v\u011bry kon\u010detinov\u00fdch tepen, CMP, infarkt myokardu). Atypick\u00fdmi projevy mohou b\u00fdt ko\u017en\u00ed nekr\u00f3zy (10\u201320%), \u017eiln\u00ed kon\u010detinov\u00e1 gangr\u00e9na a anafylaktick\u00e1 reakce (po bolusov\u00e9 d\u00e1vce nefrakcionovan\u00e9ho heparinu). Trombocytopenie m\u016f\u017ee p\u0159edch\u00e1zet nebo n\u00e1sledovat klinick\u00e9 projevy. Po\u010det trombocyt\u016f v\u011bt\u0161inou kles\u00e1 pod 50% p\u016fvodn\u00edch hodnot, v n\u011bkter\u00fdch p\u0159\u00edpadech ale nemus\u00ed poklesnout pod 100000mm<sup>3<\/sup>. Pokles trombocyt\u016f v typick\u00fdch p\u0159\u00edpadech za\u010d\u00edn\u00e1 5\u201310 dn\u016f od za\u010d\u00e1tku pod\u00e1v\u00e1n\u00ed heparinu a pokra\u010duje 2\u20134 dny. Jindy se trombocytopenie m\u016f\u017ee objevit a\u017e po 20 dnech nebo naopak n\u00e1hle, do 24 hodin od za\u010d\u00e1tku pod\u00e1v\u00e1n\u00ed heparinu. Diagn\u00f3zu HIT potvrd\u00ed pr\u016fkaz protil\u00e1tek proti heparinu (funk\u010dn\u00ed testy \u2013 vy\u0161et\u0159en\u00ed uvol\u0148ov\u00e1n\u00ed serotoninu, vy\u0161et\u0159en\u00ed heparinov\u00e9 aktivace trombocyt\u016f a vy\u0161et\u0159en\u00ed agregace trombocyt\u016f). L\u00e9\u010dba spo\u010d\u00edv\u00e1 v okam\u017eit\u00e9m vysazen\u00ed heparinu (nefrakcionovan\u00e9ho i n\u00edzkomolekul\u00e1rn\u00edho) a v pod\u00e1v\u00e1n\u00ed p\u0159\u00edm\u00fdch inhibitor\u016f trombinu (lepirudin, bivalirudin, argatroban, dabigatran).<\/p>\n<h4 style=\"text-align: justify;\">10.4.3 Chirurgick\u00e1 terapie<\/h4>\n<h5 style=\"text-align: justify;\">10.4.3.1 Chirurgie povrchov\u00fdch \u017eil<\/h5>\n<p style=\"text-align: justify;\">P\u0159i terapii varix\u016f doln\u00edch kon\u010detin je nutno vyj\u00edt z p\u0159esn\u00e9 diagn\u00f3zy, jej\u00edm\u017e z\u00e1kladem je d\u016fkladn\u00e9 klinick\u00e9 vy\u0161et\u0159en\u00ed spolu s pe\u010dliv\u00fdm odb\u011brem anamn\u00e9zy, podpo\u0159en\u00e9 vy\u0161et\u0159en\u00edm duplexn\u00ed sonografi\u00ed a vz\u00e1cn\u011b pak flebografi\u00ed. C\u00edlem chirurgick\u00e9 l\u00e9\u010dby je vy\u0159azen\u00ed patologick\u00e9ho refluxu v epifasci\u00e1ln\u00edm \u017eiln\u00edm syst\u00e9mu, p\u0159\u00edpadn\u011b p\u0159eru\u0161en\u00ed inkompetentn\u00edch perfor\u00e1tor\u016f a resekce inkompetentn\u00edch \u017eiln\u00edch \u00fasek\u016f. Z\u00e1sadn\u00ed v\u00fdznam maj\u00ed insuficientn\u00ed \u00fast\u00ed obou safen, ale t\u00e9m\u011b\u0159 u 10% nemocn\u00fdch je reflux p\u0159\u00edtomen v \u017eil\u00e1ch p\u0159\u00edvodn\u00fdch a ne v kmenov\u00fdch. Po\u010det insuficientn\u00edch p\u0159\u00edvodn\u00fdch \u017eil se pohybuje od jedn\u00e9 do p\u011bti na jedn\u00e9 kon\u010detin\u011b. Nej\u010dast\u011bji je posti\u017eena v. arcuata posterior, pot\u00e9 v. saphena accessoria medialis a v. arcuata anterior. Tento reflux je p\u0159\u00edtomen bez insuficience VSM, VSP, perfor\u00e1tor\u016f i hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu a m\u016f\u017ee se vyvinout v kter\u00e9koliv v\u00e9n\u011b bez zjevn\u00e9ho zdroje. P\u0159i indikaci typu v\u00fdkonu je t\u0159eba si uv\u011bdomit, \u017ee v\u0161echny t\u0159i syst\u00e9my, tj. epifasci\u00e1ln\u00ed, spojkov\u00fd a hlubok\u00fd, spolu souvisej\u00ed a tvo\u0159\u00ed funk\u010dn\u00ed jednotku. Zm\u011bny v jednom syst\u00e9mu maj\u00ed za n\u00e1sledek zm\u011bny v ostatn\u00edch.<\/p>\n<h6 style=\"text-align: justify;\">INDIKACE K CHIRURGICK\u00c9 L\u00c9\u010cB\u011a:<\/h6>\n<ul>\n<li>\n<div style=\"text-align: justify;\">subjektivn\u00ed pot\u00ed\u017ee nemocn\u00e9ho,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">p\u0159edejit\u00ed komplikac\u00edm varix\u016f,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">kosmetick\u00e9 hledisko,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">thrombophlebitis superficialis.<\/div>\n<\/li>\n<\/ul>\n<h6 style=\"text-align: justify;\">KONTRAINDIKACE:<\/h6>\n<ul>\n<li>\n<div style=\"text-align: justify;\">akutn\u00ed hlubok\u00e1 \u017eiln\u00ed tromb\u00f3za,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">z\u00e1n\u011btliv\u00fd proces k\u016f\u017ee doln\u00edch kon\u010detin,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">gravidida,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">v\u011bk nad 70 let,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">t\u011b\u017ek\u00e9 aterotrombotick\u00e9 zm\u011bny tepen doln\u00edch kon\u010detin,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">v\u0161eobecn\u00e9 kontraindikace operace,<\/div>\n<\/li>\n<li>\n<div style=\"text-align: justify;\">(akutn\u00ed tromboflebitida).<\/div>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Akutn\u00ed tromboflebitida je indikac\u00ed k chirurgick\u00e9mu \u0159e\u0161en\u00ed tehdy, jedn\u00e1li se o flebitis VSM, kter\u00e1 se propaguje k \u00fast\u00ed do v. femoralis. Zde je nebezpe\u010d\u00ed embolizace.<\/p>\n<h6 style=\"text-align: justify;\">P\u0158EDOPERA\u010cN\u00cd P\u0158\u00cdPRAVA<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_334.jpg\"><img decoding=\"async\" title=\"Obr. 10 - Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed10\" alt=\"Obr. 10 - Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed10\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_334.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10<br \/>Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed10<\/p><\/div>\n<p>P\u0159ed operac\u00ed je pacientovi oholena cel\u00e1 operovan\u00e1 kon\u010detina a oblast t\u0159\u00edsla. Vzhledem k tomu, \u017ee p\u0159i holen\u00ed vznikaj\u00ed drobn\u00e1 traumata s mo\u017enost\u00ed infekce, je pacient oholen t\u011bsn\u011b p\u0159ed operac\u00ed. Pot\u00e9 operat\u00e9r na stoj\u00edc\u00edm nemocn\u00e9m nesm\u00fdvatelnou tu\u017ekou ozna\u010d\u00ed varixy, nebo\u0165 v horizont\u00e1ln\u00ed poloze na opera\u010dn\u00edm stole dojde ke kolapsu a vypr\u00e1zdn\u011bn\u00ed v\u00e9n a ty ji\u017e nejsou vid\u011bt. Peropera\u010dn\u00ed vyhled\u00e1n\u00ed neozna\u010den\u00fdch v\u00e9n tak\u00e9 zhor\u0161uje pou\u017eit\u00ed barevn\u00e9ho dezinfek\u010dn\u00edho roztoku (obr. 10).<\/p>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">10.4.3.1.1 Striping VSM<\/h6>\n<p style=\"text-align: justify;\">Pacient je na opera\u010dn\u00edm stole ulo\u017een v poloze na z\u00e1dech. Prov\u00e1d\u00edme toiletu opera\u010dn\u00edho pole a jeho zarou\u0161kov\u00e1n\u00ed s d\u016frazem na oblast genit\u00e1lu. \u0158ez je veden v t\u0159\u00edsle, medi\u00e1ln\u011b od hmatn\u00e9 pulzace femor\u00e1ln\u00ed tepny,dostate\u010dn\u011b vysoko, t\u00e9m\u011b\u0159 v ohybov\u00e9 r\u00fdze, paraleln\u011b s n\u00ed. Je t\u0159eba se vyvarovat n\u00edzko ulo\u017een\u00e9ho \u0159ezu. Je nebezpe\u010d\u00ed ponech\u00e1n\u00ed v\u011btve safeny, kter\u00e1 pak m\u016f\u017ee b\u00fdt zdrojem recidivy. Velk\u00fd v\u00fdznam m\u00e1 pe\u010dliv\u00e1 preparace v t\u0159\u00edsle a podvaz v\u0161ech v\u011btv\u00ed bulbu. Je vhodn\u00e9 vypreparovat \u00fast\u00ed safeny do v. femoralis, aby nedo\u0161lo k p\u0159ehl\u00e9dnut\u00ed eventu\u00e1ln\u011b samostatn\u011b \u00fast\u00edc\u00ed v\u011bt\u00e9vky do femor\u00e1ln\u00ed \u017e\u00edly. Mysl\u00edme i na \u0159adu anatomick\u00fdch variant, zejm\u00e9na na tzv. Hvariantu, kdy inguin\u00e1ln\u00ed nebo abdomin\u00e1ln\u00ed v\u00e9ny komunikuj\u00ed se \u017e\u00edlami stehna, ani\u017e by \u00fastily do hv\u011bzdice VSM. Po vypreparov\u00e1n\u00ed velk\u00e9 safeny a ligatu\u0159e jejich p\u0159\u00edtok\u016f je tato mezi dv\u011bma pe\u00e1ny pro\u0165ata a centr\u00e1ln\u00ed pah\u00fdl dvakr\u00e1t ligov\u00e1n nevst\u0159ebateln\u00fdm vl\u00e1knem. Hovo\u0159\u00edme o tzv. krosektomii (z franc. crosse \u2013 biskupsk\u00e1 berla, kterou \u00fast\u00ed VSM do VF p\u0159ipom\u00edn\u00e1). N\u00e1zev krosektomie se pou\u017e\u00edv\u00e1 i pro v\u00fdkon v oblasti vy\u00fast\u011bn\u00ed VSP, i kdy\u017e zde je morfologie odli\u0161n\u00e1. Krosektomii mus\u00edme odli\u0161it od vysok\u00e9 ligatury VSM, p\u0159i kter\u00e9 jsou jej\u00ed v\u011btve ponech\u00e1ny. V praxi ale nejsou oba term\u00edny d\u016fsledn\u011b rozli\u0161ov\u00e1ny. Prov\u00e1d\u00edme-li tot\u00e1ln\u00ed striping, tj. odstra\u0148ujeme-li celou VSM, pronikneme lankem striperu a\u017e k vnit\u0159n\u00edmu kotn\u00edku. Retrogr\u00e1dn\u00ed pronik\u00e1n\u00ed m\u016f\u017ee b\u00fdt obt\u00ed\u017en\u00e9, a n\u011bkdy je proto vhodn\u011bj\u0161\u00ed vyhledat po\u010d\u00e1tek VSM p\u0159ed vnit\u0159n\u00edm kotn\u00edkem. Sondu pak zav\u00e1d\u00edme z periferie sm\u011brem do t\u0159\u00edsla. Pr\u016fb\u011bh lanka striperu kontrolujeme palpa\u010dn\u011b i vizu\u00e1ln\u011b, abychom se p\u0159esv\u011bd\u010dili o jeho epifasci\u00e1ln\u00edm pr\u016fb\u011bhu. Zejm\u00e9na p\u0159i pronik\u00e1n\u00ed sondou z periferie sm\u011brem centr\u00e1ln\u00edm m\u016f\u017ee doj\u00edt k jej\u00edmu sklouznut\u00ed do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu. Olivku pak hmat\u00e1me v t\u0159\u00edsle ve v. femoralis. Pokud bychom to p\u0159ehl\u00e9dli, mohlo by doj\u00edt k jej\u00edmu poran\u011bn\u00ed. Striping VSM je vhodn\u00e9 prov\u00e1d\u011bt a\u017e na konec operace, tj. po odstran\u011bn\u00ed uzl\u016f a\/nebo stripingu mal\u00e9 safeny, sou\u010dasn\u011b s nalo\u017een\u00edm elastick\u00e9 band\u00e1\u017ee od \u0161pi\u010dek prst\u016f p\u0159es patu a\u017e po t\u0159\u00edslo. V\u00e9na je stripov\u00e1na pomal\u00fdm st\u00e1l\u00fdm tahem sm\u011brem krani\u00e1ln\u00edm. C\u00edlem tohoto postupu je zabr\u00e1nit tvorb\u011b hematomu. Je samoz\u0159ejm\u011b mo\u017en\u00e9 stripovat sm\u011brem perifern\u00edm. Up\u0159ednost\u0148ujeme <i>limitovan\u00fd striping <\/i>p\u0159ed odstran\u011bn\u00edm cel\u00e9 safeny, pokud je to mo\u017en\u00e9. Z t\u0159\u00edsla retrogr\u00e1dn\u011b zavedeme sondu pod kolenn\u00ed kloub. Zde z mal\u00e9 incize vyhled\u00e1me velkou safenu, protneme ji, perifern\u00ed \u010d\u00e1st ligujeme vst\u0159ebateln\u00fdm materi\u00e1lem a ponech\u00e1v\u00e1me in situ, centr\u00e1ln\u00ed stripujeme. Retrogr\u00e1dn\u00ed pronik\u00e1n\u00ed sondou je obt\u00ed\u017en\u011bj\u0161\u00ed vzhledem k p\u0159\u00edtomnosti chlopn\u00ed, po z\u00edsk\u00e1n\u00ed cviku ale ne\u010din\u00ed v\u011bt\u0161\u00ed pot\u00ed\u017ee. Nen\u00edli p\u0159ece jenom mo\u017en\u00e9 takto sondu zav\u00e9st, pak je nutno velkou safenu vyhledat pod kolenem na ventromedi\u00e1ln\u00ed plo\u0161e b\u00e9rce a zav\u00e9st ji z periferie sm\u011brem centr\u00e1ln\u00edm. V dist\u00e1ln\u00ed \u010d\u00e1sti b\u00e9rce m\u00e1 VSM intimn\u00ed vztah k n. saphenus. P\u0159i stripingu m\u016f\u017ee doj\u00edt k jeho traumatizaci s n\u00e1slednou n\u011bkolikam\u011bs\u00ed\u010dn\u00ed a\u017e trvalou anestezi\u00ed nebo parestezi\u00ed v oblasti vnit\u0159n\u00edho kotn\u00edku. Limitovan\u00fd striping ponech\u00e1v\u00e1 perifern\u00ed neposti\u017eenou VSM in situ, co\u017e m\u00e1 v\u00fdznam i pro p\u0159\u00edpadn\u00fd rekonstruk\u010dn\u00ed tepenn\u00fd v\u00fdkon v budoucnosti, nebo\u0165 VSM je st\u00e1le ide\u00e1ln\u00ed materi\u00e1l pro rekonstruk\u010dn\u00ed v\u00fdkony. P\u0159i limitovan\u00e9m stripingu je vhodn\u00e9 v\u00e9st \u0159ez pod kolenn\u00edm kloubem. Z tohoto m\u00edsta lze dob\u0159e odstranit uzly stehna i b\u00e9rce Smetanov\u00fdm no\u017eem. Velk\u00e9 varik\u00f3zn\u00ed uzly se odstra\u0148uj\u00ed z mal\u00fdch inciz\u00ed, bu\u010f za pou\u017eit\u00ed Smetanova no\u017ee, nebo je mo\u017eno pou\u017e\u00edt v\u00edce mal\u00fdch inciz\u00ed s v\u011bdom\u00edm hor\u0161\u00edho kosmetick\u00e9ho efektu a uzly exstirpovat pomoc\u00ed pe\u00e1n\u016f. Z jednoho \u0159ezu lze \u010dasto z\u00edskat p\u0159\u00edstup k v\u00edce oblastem a vyvarovat se tak zbyte\u010dn\u011b mnoha inciz\u00ed. Velk\u00e9 uzly a konvoluty lze touto technikou snadno odstranit, ani\u017e by do\u0161lo k po\u0161kozen\u00ed jin\u00fdch struktur. Exstirpovat velk\u00e9 uzly z jednotliv\u00fdch inciz\u00ed je kosmeticky m\u00e9n\u011b p\u0159\u00edzniv\u00e9. Kosmetick\u00e9 hledisko ale mus\u00ed ustoupit p\u0159i rozs\u00e1hl\u00fdch varixech a ji\u017e po\u010d\u00ednaj\u00edc\u00edch trofick\u00fdch zm\u011bn\u00e1ch. Ko\u017en\u00ed \u0159ez m\u00e1 b\u00fdt tak velk\u00fd, jak je nutn\u00e9, a tak mal\u00fd, jak je mo\u017en\u00e9.<\/p>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">10.4.3.1.2 Striping VSP<\/h6>\n<p style=\"text-align: justify;\">Chirurgie VSP spo\u010d\u00edv\u00e1 v krosektomii (i kdy\u017e nen\u00ed tento term\u00edn pro VSP zcela spr\u00e1vn\u00fd) a parci\u00e1ln\u00ed nebo kompletn\u00ed resekci kmene VSP. Striping mal\u00e9 skryt\u00e9 \u017e\u00edly se \u0159\u00edd\u00ed stejn\u00fdmi pravidly jako striping velk\u00e9. V bl\u00edzkosti vy\u00fast\u011bn\u00ed VSP do v. poplitea jsou a. poplitea a n. tibialis. Nav\u00edc zde mohou b\u00fdt variace vy\u00fast\u011bn\u00ed VSP. D\u016fle\u017eit\u00e9 je vysok\u00e9 vy\u00fast\u011bn\u00ed. Pokud je p\u0159ehl\u00e9dnuto, m\u00e1 za n\u00e1sledek ligaturu um\u00edst\u011bnou p\u0159\u00edli\u0161 n\u00edzko s ponech\u00e1n\u00edm v\u011btv\u00ed VSP, kter\u00e9 pak mohou b\u00fdt zdrojem recidivy. P\u0159ed operac\u00ed je nutno zjistit typ \u00fast\u00ed VSP. To m\u016f\u017eeme prov\u00e9st a\u017e na opera\u010dn\u00edm s\u00e1le u pacienta le\u017e\u00edc\u00edho na boku nebo na b\u0159i\u0161e s m\u00edrn\u00fdm sklopen\u00edm stolu hlavou dol\u016f. Po punkci v\u011btve VSP aplikujeme kontrastn\u00ed l\u00e1tku a na obrazovce identifikujeme m\u00edsto \u00fast\u00ed VSP. Tento postup prodlu\u017euje operaci a je zat\u011b\u017euj\u00edc\u00ed z hlediska radia\u010dn\u00ed hygieny. Za vhodn\u011bj\u0161\u00ed pova\u017eujeme vy\u0161et\u0159en\u00ed duplexn\u00ed ultrasonografi\u00ed p\u0159ed operac\u00ed, nejl\u00e9pe operat\u00e9rem. V\u00fdkon prov\u00e1d\u00edme v poloze nemocn\u00e9ho na b\u0159i\u0161e s m\u00edrn\u011b podlo\u017eenou nohou v oblasti n\u00e1rtu, m\u00e9n\u011b vhodn\u00e1 je poloha na boku. Jeli sou\u010dasn\u011b prov\u00e1d\u011bn v\u00fdkon i na VSM, pak operujeme v poloze na z\u00e1dech s t\u00edm, \u017ee asistent elevuje kon\u010detinu a po celou dobu preparace ji dr\u017e\u00ed v t\u00e9to poloze, nebo b\u011bhem operace pacienta obr\u00e1t\u00edme z polohy na z\u00e1dech do polohy na b\u0159i\u0161e a zp\u011bt. Je nutn\u00e1 nov\u00e1 toileta opera\u010dn\u00edho pole a p\u0159erou\u0161kov\u00e1n\u00ed. Vedeme p\u0159\u00ed\u010dn\u00fd \u0159ez ve fossa poplitea, p\u0159i vysok\u00e9m \u00fast\u00ed v\u00fd\u0161e, dle p\u0159edopera\u010dn\u00edho klinick\u00e9ho a zejm\u00e9na ultrazvukov\u00e9ho vy\u0161et\u0159en\u00ed. P\u0159\u00ed\u010dn\u011b protneme fascii, pod kterou najdeme VSP. VSP protneme, provedeme ligaturu centr\u00e1ln\u00edho pah\u00fdlu a do perifern\u00edho zavedeme striper, kter\u00fdm pronikneme do poloviny b\u00e9rce nebo a\u017e nad kotn\u00edk. Je mo\u017en\u00fd i postup obr\u00e1cen\u00fd, kdy z mal\u00e9 incize za zevn\u00edm kotn\u00edkem vyhled\u00e1me po\u010d\u00e1tek VSP. V\u00e9nu protneme, perifern\u00ed pah\u00fdl uzav\u0159eme jemnou vst\u0159ebatelnou ligaturou a do centr\u00e1ln\u00edho zavedeme striper, kter\u00fdm pronikneme a\u017e do fossa poplitea. Zde nad hmatnou sondou vedeme p\u0159\u00ed\u010dnou incizi, vyhled\u00e1me \u00fast\u00ed mal\u00e9 safeny do v. poplitea a malou skrytou \u017e\u00edlu prot\u00edn\u00e1me a ligujeme (obr. 11). P\u0159ed suturou k\u016f\u017ee uzav\u0159eme fascii ve fossa poplitea. I p\u0159i operaci VSP up\u0159ednost\u0148ujeme limitovan\u00fd striping, \u010d\u00edm\u017e se vyhneme poran\u011bn\u00ed perifern\u00edch nerv\u016f s n\u00e1sledn\u00fdmi nep\u0159\u00edjemn\u00fdmi paresteziemi v inerva\u010dn\u00ed oblasti n. suralis.<\/p>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">FLEBEKTOMIE Z MINIINCIZ\u00cd<\/h6>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">10.4.3.1.3 Jednodenn\u00ed a ambulantn\u00ed chirurgie<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_337.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 11 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplitea\" alt=\"Obr. 11 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplitea\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_337.png\" width=\"200\" height=\"174\" \/><\/a><p class=\"wp-caption-text\">Obr. 11 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplitea<\/p><\/div>\n<p style=\"text-align: justify;\">Ne ka\u017ed\u00fd pacient je posti\u017een velk\u00fdmi uzlov\u00fdmi varixy, kter\u00e9 zasahuj\u00ed celou doln\u00ed kon\u010detinu a vy\u017eaduj\u00ed poopera\u010dn\u00ed hospitalizaci. Tam, kde je ze strany pacienta z\u00e1jem a klinick\u00fd n\u00e1lez to dovol\u00ed, lze od pobytu ve zdravotnick\u00e9m za\u0159\u00edzen\u00ed upustit, nebo jej zkr\u00e1tit. V r\u00e1mci <i>jednodenn\u00ed <\/i>chirurgie je pacient operov\u00e1n v nemocnici a je propu\u0161t\u011bn v den operace nebo n\u00e1sleduj\u00edc\u00ed den, p\u0159i <i>ambulantn\u00ed <\/i>chirurgii nem\u00e1 pacient k dispozici z\u00e1zem\u00ed nemocnice. Ve\u0161ker\u00e1 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed jsou provedena ambulantn\u011b, pacient p\u0159ich\u00e1z\u00ed la\u010dn\u00fd a po ozna\u010den\u00ed varix\u016f jde na opera\u010dn\u00ed s\u00e1l. V\u00fdkon je prov\u00e1d\u011bn v m\u00edstn\u00ed, spin\u00e1ln\u00ed nebo celkov\u00e9 anestezii. M\u016f\u017ee b\u00fdt pou\u017eit blok n. femoralis pro operaci na ventromedi\u00e1ln\u00ed plo\u0161e stehna nebo blok n. cutaneus femoris lateralis, kter\u00fd inervuje later\u00e1ln\u00ed stranu stehna. Celkov\u00e1 anestezie je v\u011bt\u0161inou indikov\u00e1na p\u0159i stripingu VSM, i kdy\u017e i tento v\u00fdkon lze prov\u00e1d\u011bt v lok\u00e1ln\u00ed anestezii nebo za pou\u017eit\u00ed bloku n. femoralis. U endoven\u00f3zn\u00edch metod typu RF nebo laserov\u00e9 okluze je pou\u017e\u00edv\u00e1na periven\u00f3zn\u00ed tumescentn\u00ed anestezie. V poopera\u010dn\u00edm obdob\u00ed jsou sledov\u00e1ny ob\u011bhov\u00e9 parametry a operovan\u00e1 kon\u010detina, nedoch\u00e1z\u00edli k prosakov\u00e1n\u00ed. Pacient je pak propu\u0161t\u011bn podle rozsahu operace t\u00fd\u017e den, n\u00e1sleduj\u00edc\u00ed nebo i pozd\u011bji. Operace varix\u016f v r\u00e1mci ambulantn\u00ed \u010di jednodenn\u00ed chirurgie m\u016f\u017ee m\u00edt mnoho variant a ka\u017ed\u00e9 pracovi\u0161t\u011b si vytvo\u0159\u00ed vlastn\u00ed postup.<\/p>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">10.4.3.1.4 Chirurgie perfor\u00e1tor\u016f<\/h6>\n<p style=\"text-align: justify;\">N\u00e1zory na v\u00fdznam perfor\u00e1tor\u016f nejsou zcela jednotn\u00e9 a diskuze na toto t\u00e9ma se o\u017eivila s n\u00e1stupem miniinvazivn\u00edch postup\u016f. Po\u010d\u00e1te\u010dn\u00ed nad\u0161en\u00ed bylo postupn\u011b opu\u0161t\u011bno a v sou\u010dasn\u00e9 dob\u011b je patrn\u00e1 snaha o nalezen\u00ed konsenzu v indikaci p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f. Na perfor\u00e1tory nelze nahl\u00ed\u017eet izolovan\u011b, ale v\u017edy v souvislosti s povrchov\u00fdm a hlubok\u00fdm \u017eiln\u00edm syst\u00e9mem. Z\u00e1kladn\u00ed podm\u00ednkou je vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed, kter\u00e1 posoud\u00ed funkci chlopenn\u00edho apar\u00e1tu. Chlopenn\u00ed nedostate\u010dnost je p\u0159\u00ed\u010dinou refluxu, kter\u00fd je mo\u017eno barevnou duplexn\u00ed sonografi\u00ed nejen zjistit, ale do jist\u00e9 m\u00edry i kvantifikovat. Jeli p\u0159\u00edtomen typ posti\u017een\u00ed \u017eiln\u00edho syst\u00e9mu, p\u0159i kter\u00e9m je indikov\u00e1no p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f, pak metodou volby je dnes endoskopick\u00e1 varianta. Je v\u0161eobecn\u011b dostupn\u00e1, nen\u00ed n\u00e1ro\u010dn\u00e1 na materi\u00e1ln\u00ed vybaven\u00ed a m\u00e1 p\u0159\u00edzniv\u00e9 v\u00fdsledky. Zkracuje dobu hospitalizace a eliminuje sekund\u00e1rn\u00ed hojen\u00ed ran u pacient\u016f v pokro\u010dil\u00fdch stadi\u00edch chronick\u00e9 ven\u00f3zn\u00ed insuficience.<\/p>\n<h6>POSTUPY U\u017d\u00cdVAN\u00c9 K ELIMINACI PERFOR\u00c1TOR\u016e:<\/h6>\n<ol>\n<li>Otev\u0159en\u00e1 ligatura (modifikov\u00e1no dle Cocketta)<\/li>\n<li>Endoskopick\u00e1 subfasci\u00e1ln\u00ed disekce perfor\u00e1tor\u016f \u2013\u00a0ESDP (Subfascial Endoscopic Perforator Surgery\u00a0\u2013 SEPS, Endoscopic Subfascial Division of Perforating veins \u2013 ESDP, die endoskopische subfasziale\u00a0Diszision der Perforansvenen \u2013 ESDP)<\/li>\n<li><i>Sklerotizace<\/i><\/li>\n<\/ol>\n<ol>\n<li><strong>Otev\u0159en\u00e1 ligatura<\/strong><br \/>\nSubfasci\u00e1ln\u00ed disekci a ligaturu perfor\u00e1tor\u016f poprv\u00e9\u00a0popsal <b>Linton <\/b>v roce l938 jako metodu vhodnou\u00a0k l\u00e9\u010db\u011b pokro\u010dil\u00fdch stadi\u00ed chronick\u00e9 ven\u00f3zn\u00ed insuficience. Provedl ligaturu v. femoralis superficialis,striping cel\u00e9 VSM, striping VSP od fossa poplitea\u00a0a\u017e k zevn\u00edmu kotn\u00edku a subfasci\u00e1ln\u00ed ligaturu v\u0161ech\u00a0vv. perforantes na b\u00e9rci z dlouh\u00e9ho pod\u00e9ln\u00e9ho\u00a0\u0159ezu. V\u00fdkon zakon\u010dil resekc\u00ed \u010d\u00e1sti fascie a jej\u00edm\u00a0stehem. Linton podvazuje perfor\u00e1tory subfasci\u00e1ln\u011b, <b>Cockett <\/b>extrafasci\u00e1ln\u011b. Cockett vede dlouh\u00fd \u0159ez\u00a0na medi\u00e1ln\u00ed plo\u0161e dist\u00e1ln\u00ed t\u0159etiny b\u00e9rce, za hranou\u00a0tibiae. Je-li p\u0159\u00edtomen ulcus cruris, tak jej exciduje. Cel\u00fd v\u00fdkon je extrafasci\u00e1ln\u00ed. Tato metoda byla mnoha dal\u0161\u00edmi autor y modifikov\u00e1na. <b>Doddova <\/b>modifikace spo\u010d\u00edvala v subfasci\u00e1ln\u00edm podvazu perfor\u00e1tor\u016f. Roz\u0161\u00ed\u0159en\u00e1 je <b>segment\u00e1ln\u00ed Cockettova operace<\/b>, kdy je insuficientn\u00ed perfor\u00e1tor vypreparov\u00e1n z mal\u00e9ho \u0159ezu a subfasci\u00e1ln\u011b ligov\u00e1n. K p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f se pou\u017e\u00edvala i r\u016fzn\u00e1 dl\u00e1tka a tzv. komunikotom.<br \/>\nV roce 1955 popsal <b>Felder <\/b>operaci perfor\u00e1tor\u016f ze zadn\u00edho p\u0159\u00edstupu. V\u00fdkon prov\u00e1d\u011bl v celkov\u00e9 nebo spin\u00e1ln\u00ed anestezii, v poloze nemocn\u00e9ho na b\u0159i\u0161e. Incizi vedl v cel\u00e9 d\u00e9lce l\u00fdtka v linii pun\u010dochov\u00e9ho \u0161vu od fossa poplitea po \u00farove\u0148 kotn\u00edk\u016f a v p\u0159\u00edpad\u011b pot\u0159eby ji prodlou\u017eil pod vnit\u0159n\u00ed kotn\u00edk. Pro\u0165al fascii v cel\u00e9 d\u00e9lce ko\u017en\u00ed r\u00e1ny a odstranil celou VSP. Tupou disekc\u00ed odd\u011blil fascii od svalu a postupn\u011b p\u0159itom podvazoval v\u0161echny perfor\u00e1tory. V\u00fdkon ukon\u010dil suturou fascie, podko\u017e\u00ed a k\u016f\u017ee, nalo\u017eil kryt\u00ed a pacientovi naordinoval klid na l\u016f\u017eku po dobu deseti dn\u016f.<\/li>\n<li><strong>Endoskopick\u00e1 disekce<br \/>\nP\u0159edch\u016fdcem dne\u0161n\u00edch endoskopick\u00fdch postup\u016f\u00a0byla endoskopick\u00e1 obliterace Cockettov\u00fdch perfor\u00e1tor\u016f pomoc\u00ed laryngoskopu, kterou v roce l972\u00a0popsal <b>Bentley<\/b>.<br \/>\n<\/strong>V\u00fdkon prov\u00e1d\u011bl v celkov\u00e9 anestezii, z pod\u00e9ln\u00e9ho\u00a0\u0159ezu, asi 4 cm dlouh\u00e9ho, jen\u017e byl veden 3 cm medi\u00e1ln\u011b za hranou tibie, p\u0159ibli\u017en\u011b 10\u201315 cm pod kolenn\u00edm kloubem. Rovn\u011b\u017e tak fascii nat\u00ednal pod\u00e9ln\u011b\u00a0a osv\u011btlen\u00fdm laryngoskopem ji elevoval. Perfor\u00e1tory uzav\u00edral Cushingov\u00fdmi klipy.<br \/>\nMetoda v\u0161ak doznala v\u011bt\u0161\u00edho roz\u0161\u00ed\u0159en\u00ed a\u017e v roce\u00a0l985 d\u00edky <b>Hauerovi<\/b>, kter\u00fd pou\u017eil nov\u011b vyvinut\u00e9 instrumentarium firmy Wolf. V sou\u010dasnosti je\u00a0aparatura nab\u00edzena v\u00edce firmami, p\u0159i\u010dem\u017e mezi\u00a0nimi nejsou podstatn\u00e9 rozd\u00edly. A\u017e na v\u00fdjimky jsou\u00a0v\u0161echny p\u0159\u00edstroje napojeny na obrazovku s mo\u017enost\u00ed videoz\u00e1znamu.<br \/>\nOperat\u00e9r s asistentem stoj\u00ed na stran\u011b operovan\u00e9\u00a0kon\u010detiny, video pak u nohou pacienta. Incizi, cca\u00a03 cm dlouhou, provedeme na ventromedi\u00e1ln\u00ed plo\u0161e b\u00e9rce v jeho horn\u00ed polovin\u011b. Mus\u00ed b\u00fdt um\u00edst\u011bna\u00a0do zdrav\u00e9 k\u016f\u017ee, prost\u00e9 trofick\u00fdch zm\u011bn, kter\u00e9 jsou\u00a0v\u017edy p\u0159\u00edtomny u pacient\u016f s CVI indikovan\u00fdch\u00a0k ESDP. Vhodn\u00e9 je incidovat k\u016f\u017ei nad varik\u00f3zn\u00edm\u00a0uzlem, kter\u00fd je sou\u010dasn\u011b odstran\u011bn. Pronik\u00e1me\u00a0k fascii a po jej\u00edm oz\u0159ejm\u011bn\u00ed ji pod\u00e9ln\u011b prot\u00edn\u00e1me.Digit\u00e1ln\u011b pronik\u00e1me do subfasci\u00e1ln\u00edho prostoru,\u00a0kde vytv\u00e1\u0159\u00edme dostatek prostoru pro zaveden\u00ed endoskopu. Toho lze doc\u00edlit i pomoci firemn\u00edch balon\u016f, v\u00fdsledek je stejn\u00fd, operace se ale prodra\u017euje.\u00a0Nejd\u0159\u00edve zav\u00e1d\u00edme tubus mezi fascii a sval a tup\u011b\u00a0je od sebe odd\u011blujeme, pot\u00e9 je do tubusu zasunuta\u00a0kamera.\u00a0Aplikujeme kysli\u010dn\u00edk uhli\u010dit\u00fd, n\u00e1sledkem \u010deho\u017e je opera\u010dn\u00ed pole velmi dob\u0159e p\u0159ehledn\u00e9. Perfor\u00e1tory jsou patrn\u00e9 jako v\u00e9ny prob\u00edhaj\u00edc\u00ed mezi svalem a fasci\u00ed. Pod p\u0159\u00edmou kontrolou zrakem je koagulujeme a prot\u00edn\u00e1me.<br \/>\nZa indikaci k ESDP pova\u017eujeme p\u0159\u00edtomnost insuficientn\u00edch perfor\u00e1tor\u016f v ter\u00e9nu po\u0161kozen\u00e9 ko\u017en\u00ed trofiky, kde klasick\u00fd postup nezaru\u010duje optim\u00e1ln\u00ed v\u00fdsledky. Jedn\u00e1 se o pacienty ve stadiu C4\u2013C6 chronick\u00e9 ven\u00f3zn\u00ed insuficience.<\/li>\n<li>Sklerotizace<br \/>\nSklerotizaci perfor\u00e1tor\u016f neprov\u00e1d\u00edme pro riziko\u00a0pr\u016fniku sklerotiza\u010dn\u00edho roztoku do hlubok\u00e9ho\u00a0\u017eiln\u00edho syst\u00e9mu.<\/li>\n<\/ol>\n<h6 class=\"mceTemp\" style=\"text-align: justify;\">10.4.3.1.4 Chirurgie perfor\u00e1tor\u016f<\/h6>\n<p style=\"text-align: justify;\">N\u00e1zory na v\u00fdznam perfor\u00e1tor\u016f nejsou zcela jednotn\u00e9 a diskuze na toto t\u00e9ma se o\u017eivila s n\u00e1stupem miniinvazivn\u00edch postup\u016f. Po\u010d\u00e1te\u010dn\u00ed nad\u0161en\u00ed bylo postupn\u011b opu\u0161t\u011bno a v sou\u010dasn\u00e9 dob\u011b je patrn\u00e1 snaha o nalezen\u00ed konsenzu v indikaci p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f. Na perfor\u00e1tory nelze nahl\u00ed\u017eet izolovan\u011b, ale v\u017edy v souvislosti s povrchov\u00fdm a hlubok\u00fdm \u017eiln\u00edm syst\u00e9mem. Z\u00e1kladn\u00ed podm\u00ednkou je vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed, kter\u00e1 posoud\u00ed funkci chlopenn\u00edho apar\u00e1tu. Chlopenn\u00ed nedostate\u010dnost je p\u0159\u00ed\u010dinou refluxu, kter\u00fd je mo\u017eno barevnou duplexn\u00ed sonografi\u00ed nejen zjistit, ale do jist\u00e9 m\u00edry i kvantifikovat. Jeli p\u0159\u00edtomen typ posti\u017een\u00ed \u017eiln\u00edho syst\u00e9mu, p\u0159i kter\u00e9m je indikov\u00e1no p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f, pak metodou volby je dnes endoskopick\u00e1 varianta. Je v\u0161eobecn\u011b dostupn\u00e1, nen\u00ed n\u00e1ro\u010dn\u00e1 na materi\u00e1ln\u00ed vybaven\u00ed a m\u00e1 p\u0159\u00edzniv\u00e9 v\u00fdsledky. Zkracuje dobu hospitalizace a eliminuje sekund\u00e1rn\u00ed hojen\u00ed ran u pacient\u016f v pokro\u010dil\u00fdch stadi\u00edch chronick\u00e9 ven\u00f3zn\u00ed insuficience.<\/p>\n<h6>POSTUPY U\u017d\u00cdVAN\u00c9 K ELIMINACI PERFOR\u00c1TOR\u016e:<\/h6>\n<ol>\n<li>Otev\u0159en\u00e1 ligatura (modifikov\u00e1no dle Cocketta)<\/li>\n<li>Endoskopick\u00e1 subfasci\u00e1ln\u00ed disekce perfor\u00e1tor\u016f \u2013\u00a0ESDP (Subfascial Endoscopic Perforator Surgery\u00a0\u2013 SEPS, Endoscopic Subfascial Division of Perforating veins \u2013 ESDP, die endoskopische subfasziale\u00a0Diszision der Perforansvenen \u2013 ESDP)<\/li>\n<li><i>Sklerotizace<\/i><\/li>\n<\/ol>\n<ol>\n<li><strong>Otev\u0159en\u00e1 ligatura<\/strong><br \/>\nSubfasci\u00e1ln\u00ed disekci a ligaturu perfor\u00e1tor\u016f poprv\u00e9\u00a0popsal <b>Linton <\/b>v roce l938 jako metodu vhodnou\u00a0k l\u00e9\u010db\u011b pokro\u010dil\u00fdch stadi\u00ed chronick\u00e9 ven\u00f3zn\u00ed insuficience. Provedl ligaturu v. femoralis superficialis,striping cel\u00e9 VSM, striping VSP od fossa poplitea\u00a0a\u017e k zevn\u00edmu kotn\u00edku a subfasci\u00e1ln\u00ed ligaturu v\u0161ech\u00a0vv. perforantes na b\u00e9rci z dlouh\u00e9ho pod\u00e9ln\u00e9ho\u00a0\u0159ezu. V\u00fdkon zakon\u010dil resekc\u00ed \u010d\u00e1sti fascie a jej\u00edm\u00a0stehem. Linton podvazuje perfor\u00e1tory subfasci\u00e1ln\u011b, <b>Cockett <\/b>extrafasci\u00e1ln\u011b. Cockett vede dlouh\u00fd \u0159ez\u00a0na medi\u00e1ln\u00ed plo\u0161e dist\u00e1ln\u00ed t\u0159etiny b\u00e9rce, za hranou\u00a0tibiae. Je-li p\u0159\u00edtomen ulcus cruris, tak jej exciduje. Cel\u00fd v\u00fdkon je extrafasci\u00e1ln\u00ed. Tato metoda byla mnoha dal\u0161\u00edmi autor y modifikov\u00e1na. <b>Doddova <\/b>modifikace spo\u010d\u00edvala v subfasci\u00e1ln\u00edm podvazu perfor\u00e1tor\u016f. Roz\u0161\u00ed\u0159en\u00e1 je <b>segment\u00e1ln\u00ed Cockettova operace<\/b>, kdy je insuficientn\u00ed perfor\u00e1tor vypreparov\u00e1n z mal\u00e9ho \u0159ezu a subfasci\u00e1ln\u011b ligov\u00e1n. K p\u0159eru\u0161en\u00ed perfor\u00e1tor\u016f se pou\u017e\u00edvala i r\u016fzn\u00e1 dl\u00e1tka a tzv. komunikotom.<br \/>\nV roce 1955 popsal <b>Felder <\/b>operaci perfor\u00e1tor\u016f ze zadn\u00edho p\u0159\u00edstupu. V\u00fdkon prov\u00e1d\u011bl v celkov\u00e9 nebo spin\u00e1ln\u00ed anestezii, v poloze nemocn\u00e9ho na b\u0159i\u0161e. Incizi vedl v cel\u00e9 d\u00e9lce l\u00fdtka v linii pun\u010dochov\u00e9ho \u0161vu od fossa poplitea po \u00farove\u0148 kotn\u00edk\u016f a v p\u0159\u00edpad\u011b pot\u0159eby ji prodlou\u017eil pod vnit\u0159n\u00ed kotn\u00edk. Pro\u0165al fascii v cel\u00e9 d\u00e9lce ko\u017en\u00ed r\u00e1ny a odstranil celou VSP. Tupou disekc\u00ed odd\u011blil fascii od svalu a postupn\u011b p\u0159itom podvazoval v\u0161echny perfor\u00e1tory. V\u00fdkon ukon\u010dil suturou fascie, podko\u017e\u00ed a k\u016f\u017ee, nalo\u017eil kryt\u00ed a pacientovi naordinoval klid na l\u016f\u017eku po dobu deseti dn\u016f.<\/li>\n<li><strong>Endoskopick\u00e1 disekce<br \/>\nP\u0159edch\u016fdcem dne\u0161n\u00edch endoskopick\u00fdch postup\u016f\u00a0byla endoskopick\u00e1 obliterace Cockettov\u00fdch perfor\u00e1tor\u016f pomoc\u00ed laryngoskopu, kterou v roce l972\u00a0popsal <b>Bentley<\/b>.<br \/>\n<\/strong>V\u00fdkon prov\u00e1d\u011bl v celkov\u00e9 anestezii, z pod\u00e9ln\u00e9ho\u00a0\u0159ezu, asi 4 cm dlouh\u00e9ho, jen\u017e byl veden 3 cm medi\u00e1ln\u011b za hranou tibie, p\u0159ibli\u017en\u011b 10\u201315 cm pod kolenn\u00edm kloubem. Rovn\u011b\u017e tak fascii nat\u00ednal pod\u00e9ln\u011b\u00a0a osv\u011btlen\u00fdm laryngoskopem ji elevoval. Perfor\u00e1tory uzav\u00edral Cushingov\u00fdmi klipy.<br \/>\nMetoda v\u0161ak doznala v\u011bt\u0161\u00edho roz\u0161\u00ed\u0159en\u00ed a\u017e v roce\u00a0l985 d\u00edky <b>Hauerovi<\/b>, kter\u00fd pou\u017eil nov\u011b vyvinut\u00e9 instrumentarium firmy Wolf. V sou\u010dasnosti je\u00a0aparatura nab\u00edzena v\u00edce firmami, p\u0159i\u010dem\u017e mezi\u00a0nimi nejsou podstatn\u00e9 rozd\u00edly. A\u017e na v\u00fdjimky jsou\u00a0v\u0161echny p\u0159\u00edstroje napojeny na obrazovku s mo\u017enost\u00ed videoz\u00e1znamu.<br \/>\nOperat\u00e9r s asistentem stoj\u00ed na stran\u011b operovan\u00e9\u00a0kon\u010detiny, video pak u nohou pacienta. Incizi, cca\u00a03 cm dlouhou, provedeme na ventromedi\u00e1ln\u00ed plo\u0161e b\u00e9rce v jeho horn\u00ed polovin\u011b. Mus\u00ed b\u00fdt um\u00edst\u011bna\u00a0do zdrav\u00e9 k\u016f\u017ee, prost\u00e9 trofick\u00fdch zm\u011bn, kter\u00e9 jsou\u00a0v\u017edy p\u0159\u00edtomny u pacient\u016f s CVI indikovan\u00fdch\u00a0k ESDP. Vhodn\u00e9 je incidovat k\u016f\u017ei nad varik\u00f3zn\u00edm\u00a0uzlem, kter\u00fd je sou\u010dasn\u011b odstran\u011bn. Pronik\u00e1me\u00a0k fascii a po jej\u00edm oz\u0159ejm\u011bn\u00ed ji pod\u00e9ln\u011b prot\u00edn\u00e1me.Digit\u00e1ln\u011b pronik\u00e1me do subfasci\u00e1ln\u00edho prostoru,\u00a0kde vytv\u00e1\u0159\u00edme dostatek prostoru pro zaveden\u00ed endoskopu. Toho lze doc\u00edlit i pomoci firemn\u00edch balon\u016f, v\u00fdsledek je stejn\u00fd, operace se ale prodra\u017euje.\u00a0Nejd\u0159\u00edve zav\u00e1d\u00edme tubus mezi fascii a sval a tup\u011b\u00a0je od sebe odd\u011blujeme, pot\u00e9 je do tubusu zasunuta\u00a0kamera.\u00a0Aplikujeme kysli\u010dn\u00edk uhli\u010dit\u00fd, n\u00e1sledkem \u010deho\u017e je opera\u010dn\u00ed pole velmi dob\u0159e p\u0159ehledn\u00e9. Perfor\u00e1tory jsou patrn\u00e9 jako v\u00e9ny prob\u00edhaj\u00edc\u00ed mezi svalem a fasci\u00ed. Pod p\u0159\u00edmou kontrolou zrakem je koagulujeme a prot\u00edn\u00e1me.<br \/>\nZa indikaci k ESDP pova\u017eujeme p\u0159\u00edtomnost insuficientn\u00edch perfor\u00e1tor\u016f v ter\u00e9nu po\u0161kozen\u00e9 ko\u017en\u00ed trofiky, kde klasick\u00fd postup nezaru\u010duje optim\u00e1ln\u00ed v\u00fdsledky. Jedn\u00e1 se o pacienty ve stadiu C4\u2013C6 chronick\u00e9 ven\u00f3zn\u00ed insuficience.<\/li>\n<li>Sklerotizace<br \/>\nSklerotizaci perfor\u00e1tor\u016f neprov\u00e1d\u00edme pro riziko\u00a0pr\u016fniku sklerotiza\u010dn\u00edho roztoku do hlubok\u00e9ho\u00a0\u017eiln\u00edho syst\u00e9mu.<\/li>\n<\/ol>\n<h6>10.4.3.1.5 Komplikace chirurgick\u00e9 terapie<\/h6>\n<p>Komplikace v chirurgii \u017eiln\u00edho syst\u00e9mu jsou vz\u00e1cn\u00e9 a v\u011bt\u0161inou v\u00fdrazn\u011b neohro\u017euj\u00ed pacienta. M\u016f\u017eeme se s nimi setkat jak p\u0159i operaci, tak po n\u00ed.<\/p>\n<h6>PEROPERA\u010cN\u00cd KOMPLIKACE<\/h6>\n<ol>\n<li><strong>Krv\u00e1cen\u00ed<\/strong><br \/>\nStriping VSM\/VSP je doprov\u00e1zen krv\u00e1cen\u00edm z jej\u00edch v\u011btv\u00ed. Toto krv\u00e1cen\u00ed ustane po nalo\u017een\u00ed elastick\u00e9 band\u00e1\u017ee. Proto prov\u00e1d\u00edme striping a\u017e na konci\u00a0operace a sou\u010dasn\u011b s n\u00edm nakl\u00e1d\u00e1me elastickou\u00a0band\u00e1\u017e. P\u0159i invagina\u010dn\u00edm stripingu b\u00fdv\u00e1 krv\u00e1cen\u00ed men\u0161\u00ed. Ka\u017ed\u00e9 krv\u00e1cen\u00ed je nutno pe\u010dliv\u011b o\u0161et\u0159it\u00a0z hlediska prevence vzniku hematomu v r\u00e1n\u011b.<\/li>\n<li><strong>Poran\u011bn\u00ed velk\u00fdch c\u00e9v<\/strong><br \/>\nSe z\u00e1va\u017en\u011bj\u0161\u00edm peropera\u010dn\u00edm krv\u00e1cen\u00edm se setk\u00e1v\u00e1me v\u011bt\u0161inou p\u0159i preparaci v oblasti bulbu VSM\u00a0nebo ve fossa poplitea. M\u016f\u017ee nastat jednak m\u00e9n\u011b<br \/>\nz\u00e1va\u017en\u00e9 krv\u00e1cen\u00ed z poran\u011bn\u00ed v\u011btv\u00ed bulbu \u010di samotn\u00e9\u00a0safeny, tak hroziv\u011bj\u0161\u00ed krv\u00e1cen\u00ed p\u0159i poran\u011bn\u00ed femor\u00e1ln\u00edch c\u00e9v, \u010dast\u011bji v\u00e9n. Poran\u011bn\u00ed v\u00e9ny je 5\u00d7 \u010dast\u011bj\u0161\u00ed\u00a0ne\u017e tepny. Je pops\u00e1na ligatura femor\u00e1ln\u00ed i poplite\u00e1ln\u00ed arterie i striping tepny.<br \/>\nPoran\u011bn\u00ed v\u011btv\u00ed bulbu a samotn\u00e9 safeny \u0159e\u0161\u00edme ligaturou, poran\u011bn\u00ed femor\u00e1ln\u00edch c\u00e9v pak stehem.<br \/>\nP\u0159i stav\u011bn\u00ed krv\u00e1cen\u00ed je nutno postupovat velmi \u0161etrn\u011b, abychom nezp\u016fsobili dal\u0161\u00ed \u0161kody, nap\u0159\u00edklad\u00a0nalo\u017een\u00edm pe\u00e1n\u016f naslepo. Krv\u00e1cen\u00ed v\u017edy nejd\u0159\u00edve\u00a0zastav\u00edme tlakem prstu a ur\u010d\u00edme jeho zdroj, v p\u0159\u00edpad\u011b pot\u0159eby zv\u011bt\u0161\u00edme r\u00e1nu. Steh nakl\u00e1d\u00e1me na nekrv\u00e1cej\u00edc\u00ed v\u00e9nu p\u0159i jej\u00ed kompresi dv\u011bma tampony\u00a0nad a pod l\u00e9z\u00ed. P\u0159i v\u011bt\u0161\u00edm po\u0161kozen\u00ed, podvazu nebo\u00a0prot\u011bt\u00ed hlubok\u00e9 v\u00e9ny se \u0159\u00edd\u00edme z\u00e1sadami c\u00e9vn\u00ed chirurgie.\u00a0Poran\u011bn\u00ed velk\u00fdch c\u00e9v by se nem\u011blo vyskytovat.\u00a0V\u017edy mus\u00edme pe\u010dliv\u011b vypreparovat \u00fast\u00ed VSM\/VSP\u00a0do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu. Jsme-li na pochyb\u00e1ch, nikdy nesm\u00edme v\u00e9nu podv\u00e1zat, nebo dokonce stripovat.<\/li>\n<li><strong>Vniknut\u00ed ciz\u00edho t\u011blesa do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu<\/strong><br \/>\nS touto komplikac\u00ed jsme se sami setkali pouze jedenkr\u00e1t (Herman, 2000). Jednalo se o odlomen\u00ed konce stripovac\u00ed sondy a jej\u00ed vycestov\u00e1n\u00ed do v. iliaca interna, co\u017e si vy\u017e\u00e1dalo opera\u010dn\u00ed revizi s vypreparov\u00e1n\u00edm ilick\u00fdch v\u00e9n. Alternativn\u00edm postupem by bylo odstran\u011bn\u00ed metodami interven\u010dn\u00ed radiologie. \u010cast\u011bji se s ciz\u00edm t\u011blesem v hlubok\u00e9m \u017eiln\u00edm syst\u00e9mu m\u016f\u017eeme setkat v souvislosti s interven\u010dn\u00ed radiologi\u00ed.<\/li>\n<\/ol>\n<p>POOPERA\u010cN\u00cd KOMPLIKACE<\/p>\n<ol>\n<li><strong>Hematom<\/strong><br \/>\nHematom se nej\u010dast\u011bji vyskytuje v oblasti ventromedi\u00e1ln\u00ed plochy b\u00e9rce a stehna, tj. v pr\u016fb\u011bhu velk\u00e9\u00a0safeny. Jsou-li hematomy mal\u00e9, vst\u0159ebaj\u00ed se bez v\u011bt\u0161\u00edch probl\u00e9m\u016f. U rozs\u00e1hlej\u0161\u00edch hematom\u016f doch\u00e1z\u00ed ke vzniku infiltr\u00e1t\u016f, \u010dasto bolestiv\u00fdch, s nebezpe\u010d\u00edm jejich infekce. Vst\u0159eb\u00e1v\u00e1n\u00ed trv\u00e1 del\u0161\u00ed dobu\u00a0a vedle aplikace mast\u00ed a obvaz\u016f si m\u016f\u017ee vy\u017e\u00e1dat\u00a0i incize a evakuace.<br \/>\nPrevenc\u00ed je \u0161etrn\u00e1 opera\u010dn\u00ed technika, nakl\u00e1d\u00e1n\u00ed\u00a0elastick\u00e9 band\u00e1\u017ee sou\u010dasn\u011b se stripingem tam,\u00a0kde je to mo\u017en\u00e9. U rozs\u00e1hlej\u0161\u00edch v\u00fdkon\u016f je nutn\u00e1\u00a0peropera\u010dn\u00ed komprese, a\u0165 ji\u017e asistentem longetou\u00a0p\u0159es k\u016f\u017ei nebo vsunut\u00edm longety do r\u00e1ny. Velkou\u00a0i malou skrytou \u017e\u00edlu stripujeme v\u017edy a\u017e na konec\u00a0operace a jen v takov\u00e9m rozsahu, kam a\u017e sahaj\u00ed\u00a0patologick\u00e9 zm\u011bny (limitovan\u00fd striping).<br \/>\nHematom v t\u0159\u00edsle m\u016f\u017ee vzniknout p\u0159i ne\u0161etrn\u00e9 preparaci v t\u00e9to oblasti z poran\u011bn\u00ed v\u011btv\u00ed bulbu nebo samotn\u00e9 safeny, vz\u00e1cn\u011bji pak z poran\u011bn\u00ed femor\u00e1ln\u00edch\u00a0c\u00e9v. Dal\u0161\u00ed p\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt sklouznut\u00ed ligatury.<br \/>\nJe zde nebezpe\u010d\u00ed jeho infekce, a proto je nutn\u00e9 oblast t\u0159\u00edsla na konci operace d\u016fkladn\u011b zkontrolovat\u00a0a vysu\u0161it. Mus\u00edme myslet i na tzv. \u201ezate\u010denou\u201c krev\u00a0z kan\u00e1lu po odstran\u011bn\u00e9 velk\u00e9 safen\u011b.<\/li>\n<li><strong>Neurologick\u00e9 komplikace<br \/>\n<\/strong>Nej\u010dast\u011bj\u0161\u00ed neurologickou komplikac\u00ed jsou parestezie v dist\u00e1ln\u00ed \u010d\u00e1sti ventromedi\u00e1ln\u00ed plochy b\u00e9rce,\u00a0zp\u016fsoben\u00e9 poran\u011bn\u00edm n. saphenus. V\u00fdskyt parestezi\u00ed je ud\u00e1v\u00e1n od 4,2% po 39%. Ni\u017e\u0161\u00ed procento\u00a0je p\u0159\u00edtomno u tzv. limitovan\u00e9ho stripingu, kdy je\u00a0VSM stripov\u00e1na jen pod koleno. Vy\u0161\u0161\u00ed procento\u00a0pak u kompletn\u00edho stripingu od hlezna po t\u0159\u00edslo.\u00a0Holme na\u0161el 6\u00d7 vy\u0161\u0161\u00ed v\u00fdskyt l\u00e9ze nervu u kompletn\u00edho stripingu proti limitovan\u00e9mu p\u0159i 10% recidiv\u011b v obou skupin\u00e1ch. V\u011bt\u0161\u00ed nebezpe\u010d\u00ed poran\u011bn\u00ed n.saphenus je p\u0159i ortogr\u00e1dn\u00edm ne\u017e p\u0159i retrogr\u00e1dn\u00edm\u00a0stripingu.<\/li>\n<li>Vz\u00e1cnou, ale z\u00e1va\u017enou komplikac\u00ed je l\u00e9ze n. peroneus communis, kter\u00fd prob\u00edh\u00e1 po medi\u00e1ln\u00edm okraji m. biceps femoris a nejsn\u00e1ze zraniteln\u00fd je v oblasti caput fibulae. Zde prob\u00edh\u00e1 povrchov\u011b a je kryt pouze fasci\u00ed a k\u016f\u017e\u00ed. Tuto komplikaci popsalritchley p\u0159i operaci VSP. \u00dast\u00ed do v. poplitea bylo\u00a06 cm nad poplite\u00e1ln\u00ed \u0159asou a p\u0159i jeho preparaci bylo nutno retrahovat nerv s c\u00edlem dos\u00e1hnout vysok\u00e9 ligatury VSP. Komplikace se projevila znecitliv\u011bn\u00edm dorza nohy, v\u00e1znut\u00edm extenze prst\u016f a dorz\u00e1ln\u00ed flexe nohy v hleznu. Pot\u00ed\u017ee p\u0159etrv\u00e1valy dva roky.<\/li>\n<li><strong>Lymfatick\u00e1 p\u00ed\u0161t\u011bl<\/strong><br \/>\nLymfatick\u00e1 p\u00ed\u0161t\u011bl se vyskytuje v t\u0159\u00edsle, \u010dast\u011bji u reoperac\u00ed ne\u017e u prim\u00e1rn\u00edch v\u00fdkon\u016f. P\u0159\u00ed\u010dinou b\u00fdvaj\u00ed dlouh\u00e9 p\u0159\u00ed\u010dn\u00e9 incize v jizevnat\u00e9 tk\u00e1ni. L\u00e9\u010dba\u00a0spo\u010d\u00edv\u00e1 v revizi a sutu\u0159e v lok\u00e1ln\u00ed anestezii nebo\u00a0v kompresi t\u0159\u00edsla sou\u010dasn\u011b s klidov\u00fdm re\u017eimem.Lymfatick\u00e1 p\u00ed\u0161t\u011bl m\u016f\u017ee b\u00fdt p\u0159\u00edtomna i v m\u00edst\u011b flebektomie.<\/li>\n<li><strong>Dehiscence r\u00e1ny<\/strong><br \/>\nDehiscence r\u00e1ny v t\u0159\u00edsle je komplikac\u00ed vz\u00e1cnou. Nev\u00fdhodou je prodlou\u017een\u00ed doby l\u00e9\u010den\u00ed. \u010cast\u011bj\u0161\u00ed m\u016f\u017ee\u00a0b\u00fdt v\u00fdskyt komplikovan\u00e9ho hojen\u00ed r\u00e1ny na b\u00e9rci,\u00a0zejm\u00e9na u pacient\u016f s CVI v pokro\u010dil\u00e9m stadiu, kde\u00a0jsou ji\u017e p\u0159\u00edtomny trofick\u00e9 zm\u011bny. V takov\u00fdch p\u0159\u00edpadech je nutno pacienty na mo\u017enost sekund\u00e1rn\u00edho\u00a0hojen\u00ed r\u00e1ny upozornit p\u0159ed operac\u00ed.<\/li>\n<li><strong>Tromboflebitida<\/strong><br \/>\nVz\u00e1cn\u011b m\u016f\u017ee postihnout perifern\u00ed \u010d\u00e1st kmene\u00a0VSM\/VSP p\u0159i limitovan\u00e9m stripingu nebo podvazu VSM nebo varixy, kter\u00e9 nebyly kompletn\u011b\u00a0odstran\u011bny. Koagulum z v\u00e9ny exprimujeme po jej\u00ed\u00a0incizi nebo v\u00e9nu v lok\u00e1ln\u00ed anestezii exstirpujeme.\u00a0Je-li proces rozs\u00e1hlej\u0161\u00ed, aplikujeme lok\u00e1ln\u011b antiflogistika a kompresivn\u00ed band\u00e1\u017e.<\/li>\n<li><strong>Flebotromb\u00f3za a plicn\u00ed embolie<\/strong><br \/>\nIncidence hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy po operaci varix\u016f je ud\u00e1v\u00e1na v rozmez\u00ed 0,15\u20130,5% a plicn\u00ed embolie 0,06% a\u017e 0,16%. Pravd\u011bpodobn\u011b zde nen\u00ed\u00a0souvislost s u\u017e\u00edv\u00e1n\u00edm hormon\u00e1ln\u00edch prepar\u00e1t\u016f,\u00a0v\u010detn\u011b kontraceptiv.<\/li>\n<li><strong>Tetov\u00e1\u017e<\/strong><br \/>\nP\u0159i pou\u017eit\u00ed inkoustov\u00fdch tu\u017eek k p\u0159edopera\u010dn\u00edmu\u00a0zna\u010den\u00ed varix\u016f je mo\u017eno se setkat se vznikem tetov\u00e1\u017ee. Sami jsme takovouto komplikaci nezaznamenali.<\/li>\n<\/ol>\n<h6>10.4.3.1.6 Reoperace<\/h6>\n<p>Recidiva postihuje p\u0159ibli\u017en\u011b 20\u201330% pacient\u016f operovan\u00fdch pro varixy doln\u00edch kon\u010detin. P\u0159i dlouhodob\u00e9m sledov\u00e1n\u00ed je ud\u00e1v\u00e1na recidiva a\u017e u 80%. Jones na\u0161el p\u0159i vy\u0161et\u0159en\u00ed duplexn\u00ed ultrasonografi\u00ed recidivu za dva roky u 43% pacient\u016f po krosektomii VSM a u 25% pacient\u016f po krosektomii se stripingem, i kdy\u017e 89% pacient\u016f bylo s v\u00fdsledkem operace spokojeno. Rekurence nar\u016fst\u00e1 s \u010dasem. Pr\u016fm\u011brn\u00e1 doba mezi prvn\u00ed a druhou operac\u00ed je 6\u201320 let. Vy\u0161\u0161\u00ed procento reoperac\u00ed je pozorov\u00e1no po operac\u00edch proveden\u00fdch v\u0161eobecn\u00fdm chirurgem ve srovn\u00e1n\u00ed s operacemi, kter\u00e9 provedl c\u00e9vn\u00ed chirurg.\u00a0Recidiva je jednak nep\u0159\u00edjemn\u00e1 pro pacienta, jednak zat\u011b\u017euj\u00edc\u00ed pro chirurgick\u00e9 pracovi\u0161t\u011b i pro poji\u0161\u0165ovnu.<\/p>\n<p>Kraj\u00ed\u010dek s Va\u0148kem rozli\u0161uj\u00ed rezidu\u00e1ln\u00ed m\u011bstky, tj. takov\u00e9, kter\u00e9 byly ponech\u00e1ny p\u0159i operaci, prav\u00e9 recidivy, zp\u016fsoben\u00e9 nedomykavou p\u0159\u00edmou \u010di nep\u0159\u00edmou spojkou, a neprav\u00e9 recidivy, vznikaj\u00edc\u00ed n\u00e1sledkem progrese onemocn\u011bn\u00ed ve form\u011b novotvo\u0159en\u00fdch prim\u00e1rn\u00edch varix\u016f nebo sekund\u00e1rn\u00edch v d\u016fsledku rekanalizace po prob\u011bhl\u00e9 hlubok\u00e9 \u017eiln\u00ed tromb\u00f3ze. Ta m\u00e1 za n\u00e1sledek vznik nedomykav\u00fdch spojek a n\u00e1sledn\u011b varix\u016f.<\/p>\n<p>Za recidivu lze ozna\u010dovat ty stavy, kdy je p\u0159\u00edtomen centrifug\u00e1ln\u00ed reflux z hlubok\u00e9ho do povrchov\u00e9ho \u017eiln\u00edho syst\u00e9mu, eventu\u00e1ln\u011b z v\u00fd\u0161e ulo\u017een\u00e9 v\u011btve povrchov\u00e9ho syst\u00e9mu do ni\u017e\u0161\u00edch v\u011btv\u00ed. Nen\u00ed-li p\u0159\u00edtomen reflux, nejedn\u00e1 se o recidivu, ale o progresi choroby. <i>Recidivu definujeme jako p\u0159\u00edtomnost varik\u00f3zn\u00edch \u017eil na doln\u00ed kon\u010detin\u011b pro varixy ji\u017e d\u0159\u00edve operovan\u00e9.\u00a0<\/i>V\u011bt\u0161inou je p\u0159\u00ed\u010dina v ponechan\u00e9m refluxu v safenofemor\u00e1ln\u00ed junkci. Z\u00e1va\u017enou chybou je n\u00edzk\u00e9 ulo\u017een\u00ed \u0159ezu na stehn\u011b, dist\u00e1ln\u011b od sulcus genitofemoralis. M\u016f\u017ee b\u00fdt ponech\u00e1na cel\u00e1 VSM, kdy\u017e chirurg p\u0159i operaci odstranil akcesorn\u00ed safenu a hlavn\u00ed kmen ponechal in situ. Tato situace nast\u00e1v\u00e1 tehdy, jestli\u017ee chirurg nesleduje VSM a\u017e k jej\u00edmu \u00fast\u00ed do v. femoralis. I p\u0159i odstran\u011bn\u00ed VSM m\u016f\u017ee doj\u00edt k recidiv\u011b, a to tehdy, je-li ponech\u00e1n jej\u00ed pah\u00fdl dlouh\u00fd. Z pah\u00fdlu m\u016f\u017ee odstupovat v\u011btev, kter\u00e1 se v d\u016fsledku refluxu dilatuje a je p\u0159\u00ed\u010dinou vzniku varix\u016f. Such\u00fd s Re\u010dkem popisuj\u00ed recidivu, kdy krev proud\u00ed z jedn\u00e9 v\u011btve v epifasci\u00e1ln\u00edm \u017eiln\u00edm syst\u00e9mu do druh\u00e9, pro kterou navrhli ozna\u010den\u00ed\u00a0\u201ehitch-hike\u201c, p\u0159evzat\u00fd z chirurgie tepenn\u00e9ho syst\u00e9mu. Nejde o reflux z hlubok\u00e9ho do povrchov\u00e9ho syst\u00e9mu. Takov\u00e9 uspo\u0159\u00e1d\u00e1n\u00ed v oblasti bulbu b\u00fdv\u00e1 ozna\u010dov\u00e1no jako tzv. H-varianta.<\/p>\n<p>VSM stripujeme a\u017e pod koleno, \u010d\u00edm\u017e sou\u010dasn\u011b eliminujeme stehenn\u00ed perfor\u00e1tor, kter\u00fd m\u016f\u017ee b\u00fdt zdrojem refluxu. Proto samotn\u00e1 vysok\u00e1 ligatura VSM m\u00e1 a\u017e 45% v\u00fdskyt recidivy ve VSM na b\u00e9rci, jej\u00ed\u017e p\u0159\u00ed\u010dinou je v\u011bt\u0161inou p\u0159\u00edtomnost stehenn\u00edho perfor\u00e1toru. Striping d\u00e1v\u00e1 lep\u0161\u00ed v\u00fdsledky ne\u017e vysok\u00e1 ligatura kombinovan\u00e1 se sklerotizac\u00ed.<\/p>\n<p>Z \u010d\u00e1sti recidivy je obvi\u0148ov\u00e1n proces ozna\u010dovan\u00fd jako neovaskularizace. P\u0159i n\u00ed doch\u00e1z\u00ed k tvorb\u011b nov\u00fdch tenkost\u011bnn\u00fdch vinut\u00fdch \u017eil, co\u017e je b\u011b\u017en\u00fd doprovodn\u00fd jev p\u0159i hojen\u00ed ran. Tyto nov\u011b vytvo\u0159en\u00e9 v\u00e9ny pak mohou spojit femor\u00e1ln\u00ed v\u00e9nu s epifasci\u00e1ln\u00ed v\u00e9nou nebo p\u0159\u00edmo s ponechanou safenou. K zabr\u00e1n\u011bn\u00ed neovaskularizace byly nav\u017eeny postupy, p\u0159i kter\u00fdch je safenofemor\u00e1ln\u00ed pah\u00fdl zano\u0159en, p\u0159ekryt transpozic\u00ed fascie m. pectineus nebo syntetick\u00fdm materi\u00e1lem. Tyto operace se neroz\u0161\u00ed\u0159ily.<\/p>\n<p>P\u0159\u00ed\u010dinou recidivy m\u016f\u017ee b\u00fdt ponechan\u00fd insuficientn\u00ed perfor\u00e1tor, i kdy\u017e n\u00e1zory na jeho v\u00fdznam se v posledn\u00ed dob\u011b m\u011bn\u00ed. Dle na\u0161eho n\u00e1zoru je indikace ke zru\u0161en\u00ed perfor\u00e1tor\u016f tehdy, je-li posti\u017een hlubok\u00fd \u017eiln\u00ed syst\u00e9m. P\u0159i izolovan\u00e9m refluxu v epifasci\u00e1ln\u00edm syst\u00e9mu pouze tehdy, je-li perfor\u00e1tor \u0161ir\u0161\u00ed ne\u017e 3 mm. V takov\u00e9m p\u0159\u00edpad\u011b se jeho funkce v\u011bt\u0161inou neobnov\u00ed, ani kdy\u017e eliminujeme reflux v povrchov\u00e9m \u017eiln\u00edm syst\u00e9mu. S t\u00edmto n\u00e1zorem ale ne v\u0161ichni souhlas\u00ed a doporu\u010duj\u00ed p\u0159eru\u0161it ka\u017ed\u00fd insuficientn\u00ed perfor\u00e1tor.<\/p>\n<p>Inkompetence VSP je m\u00e9n\u011b \u010dast\u00e1 ne\u017e u VSM, proto je i recidiva v jej\u00edm povod\u00ed vz\u00e1cn\u011bj\u0161\u00ed. Chceme-li zabr\u00e1nit recidiv\u011b, mus\u00edme vyhledat \u00fast\u00ed VSP subfasci\u00e1ln\u011b. P\u0159edopera\u010dn\u011b n\u00e1m pom\u016f\u017ee vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed. Pacienti s recidivou v povod\u00ed VSP se dostavuj\u00ed k reoperaci d\u0159\u00edve (50% za 6 let) ne\u017e pacienti s recidivou v povod\u00ed VSM (50% za 12 let). K recidiv\u011b varix\u016f m\u016f\u017ee p\u0159isp\u011bt i inkompetence ovari\u00e1ln\u00edch \u017eil. P\u0159i jedn\u00e9 operaci m\u016f\u017ee vzniknout v\u00edce chyb. Proto je d\u016fle\u017eit\u00e9 ka\u017ed\u00e9ho pacienta p\u0159ed reoperac\u00ed d\u016fkladn\u011b vy\u0161et\u0159it jak klinicky, tak duplexn\u00ed sonografi\u00ed.<\/p>\n<p>V mal\u00e9m procentu se p\u0159\u00ed\u010dina recidivy nezjist\u00ed. Chceme-li zabr\u00e1nit vzniku recidivy, m\u011bli bychom\u00a0dodr\u017eovat n\u00e1sleduj\u00edc\u00ed z\u00e1sady:<\/p>\n<ol>\n<li>P\u0159ed operac\u00ed pacienta d\u016fkladn\u011b vy\u0161et\u0159\u00edme (v\u017edy\u00a0operat\u00e9r) a ozna\u010d\u00edme varixy a zejm\u00e9na m\u00edsta refluxu nesm\u00fdvatelnou tu\u017ekou.<\/li>\n<li>Ka\u017ed\u00e9ho pacienta vy\u0161et\u0159\u00edme duplexn\u00ed sonografi\u00ed,\u00a0kterou prov\u00e1d\u00ed s\u00e1m operat\u00e9r nebo jeden zku\u0161en\u00fd\u00a0l\u00e9ka\u0159. Vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed je pova\u017eov\u00e1no\u00a0za zlat\u00fd standard, je zde ale mo\u017enost r\u016fzn\u00e9 interpretace v\u00fdsledk\u016f vy\u0161et\u0159en\u00ed.<\/li>\n<li>Pokud operaci neprov\u00e1d\u00ed erudovan\u00fd nebo c\u00e9vn\u00ed\u00a0chirurg, m\u011bl by j\u00ed alespo\u0148 asistovat. Recidivu mus\u00ed\u00a0operovat zku\u0161en\u00fd nebo c\u00e9vn\u00ed chirurg.<\/li>\n<li>Vyhled\u00e1n\u00ed po\u010d\u00e1tku VSM p\u0159i vnit\u0159n\u00edm kotn\u00edku, zaveden\u00ed sondy a\u017e do t\u0159\u00edsla, vyta\u017een\u00ed sondy z mal\u00e9\u00a0incize nad jej\u00edm hmatn\u00fdm proxim\u00e1ln\u00edm koncem\u00a0a n\u00e1sledn\u00fd striping je postup sice rychl\u00fd, ale opu\u0161t\u011bn\u00fd. Je zde nebezpe\u010d\u00ed ponech\u00e1n\u00ed v\u011btv\u00ed VSM p\u0159i jej\u00edm\u00a0\u00fast\u00ed, nav\u00edc je stripov\u00e1na cel\u00e1 v\u00e9na, co\u017e neb\u00fdv\u00e1 v\u011bt\u0161inou nutn\u00e9, a vede \u010dast\u011bji k neurologick\u00fdm komplikac\u00edm. Preparaci zah\u00e1j\u00edme v t\u0159\u00edsle, vyhled\u00e1me\u00a0\u00fast\u00ed VSM do VF a podv\u00e1\u017eeme v\u0161echny v\u011btve bulbu. Pot\u00e9 provedeme vysokou ligaturu VSM a do jej\u00edho perifern\u00edho pah\u00fdlu avedeme sondu a pronikneme tak dist\u00e1ln\u011b, kam a\u017e sah\u00e1 insuficience kmene VSM (zji\u0161t\u011bno klinicky a duplexn\u00ed sonografi\u00ed) \u2013 tj. pod kolenn\u00ed kloub nebo je\u0161t\u011b dist\u00e1ln\u011bji. V\u00fdskyt recidiv lze sn\u00ed\u017eit spr\u00e1vnou krosektomi\u00ed, p\u0159i n\u00ed\u017e sledujeme VSM a\u017e k jej\u00edmu \u00fast\u00ed do VF<\/li>\n<li>Ponech\u00e1v\u00e1me-li VSP in situ, mus\u00edme si b\u00fdt jisti kompetenc\u00ed jej\u00edho \u00fast\u00ed.<\/li>\n<\/ol>\n<h6>REOPERACE<\/h6>\n<p>V terapii recidivuj\u00edc\u00edch varix\u016f lze pou\u017e\u00edt l\u00e9\u010dbu chirurgickou, sklerotiza\u010dn\u00ed i jejich kombinaci. K podp\u016frn\u00e9 terapii pat\u0159\u00ed l\u00e9\u010dba medikament\u00f3zn\u00ed a kompresivn\u00ed. Z\u00e1sadn\u00ed v\u00fdznam v terapii recidiv m\u00e1 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed, kter\u00e9 ur\u010d\u00ed m\u00edsto nebo m\u00edsta refluxu. Ta je nutno liminovat. Prost\u00e9 odstran\u011bn\u00ed varix\u016f bez ohledu na zdroj refluxu m\u00e1 jen do\u010dasn\u00fd efekt a je p\u0159\u00ed\u010dinou dal\u0161\u00ed recidivy. Nen\u00ed tedy jeden typ operace pro recidivu, ale v\u017edy se zam\u011b\u0159ujeme na zdroje refluxu. Jen pokud tato m\u00edsta neur\u010d\u00edme, provedeme prostou exstirpaci varikozit.<\/p>\n<p>Dlouhodob\u00e1 \u00fasp\u011b\u0161nost reoperac\u00ed z\u00e1vis\u00ed tak\u00e9 na p\u0159\u00ed\u010din\u011b recidivy. Bude lep\u0161\u00ed u prim\u00e1rn\u00edch varix\u016f, s hor\u0161\u00edmi v\u00fdsledky lze po\u010d\u00edtat u posttrombotick\u00fdch stav\u016f.<\/p>\n<p>Preparace v t\u0159\u00edsle p\u0159i reoperaci p\u0159edstavuje vy\u0161\u0161\u00ed riziko vzniku hematomu, infekce, lymfatick\u00e9 p\u00ed\u0161t\u011ble nebo poran\u011bn\u00ed velk\u00fdch c\u00e9v, ne\u017e je tomu u prim\u00e1rn\u00ed operace. Ob\u00e1vanou komplikac\u00ed je vznik lymfed\u00e9mu. Proto je nutn\u00e9 d\u016fkladn\u00e9 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed, v\u010detn\u011b duplexn\u00edho ultrazvuku, k ur\u010den\u00ed p\u0159\u00ed\u010diny recidivy, a nen\u00ed-li tato v ponechan\u00e9 velk\u00e9 \u010di akcesorn\u00ed safen\u011b, v t\u0159\u00edsle neoperujeme. Preparace v t\u0159\u00edsle p\u0159i reoperaci je v jizevnat\u00e9 tk\u00e1ni s k\u0159ehk\u00fdmi, snadno krv\u00e1cej\u00edc\u00edmi v\u00e9nami velmi obt\u00ed\u017en\u00e1. Je proto vhodn\u00e9 zvolit later\u00e1ln\u00ed p\u0159\u00edstup, p\u0159i kter\u00e9m vedeme \u0159ez later\u00e1ln\u011b od p\u016fvodn\u00edho a pronik\u00e1me sm\u011brem medi\u00e1ln\u00edm k femor\u00e1ln\u00ed tepn\u011b. Jej\u00ed pulzace n\u00e1m slou\u017e\u00ed jako vod\u00edtko. Medi\u00e1ln\u011b od n\u00ed pak vyhled\u00e1me VF spolu s ponechan\u00fdm \u00fast\u00edm VSM. Vypreparujeme safenofemor\u00e1ln\u00ed \u00fast\u00ed, nalo\u017e\u00edme vysokou ligaturu (flush ligature) a VSM protneme.<\/p>\n<p>Je mo\u017eno pou\u017e\u00edt i medi\u00e1ln\u00ed p\u0159\u00edstup. \u0158ez je veden v t\u0159\u00edsle medi\u00e1ln\u011b a nad p\u016fvodn\u00ed jizvou. Pronikneme p\u0159\u00edmo k p\u0159edn\u00ed plo\u0161e VF a ligujeme VSM. Operat\u00e9r stoj\u00ed na opa\u010dn\u00e9 stran\u011b, ne\u017e je operovan\u00e1 kon\u010detina.<\/p>\n<p>P\u0159\u00edstup ze standardn\u00edho \u0159ezu v t\u0159\u00edsle zvol\u00edme, je-li p\u016fvodn\u00ed \u0159ez um\u00edst\u011bn atypicky, nej\u010dast\u011bji dist\u00e1ln\u011b na stehn\u011b. Nepreparujeme v jizevnat\u00e9 tk\u00e1ni a v\u00fdkon prob\u00edh\u00e1 jako prim\u00e1rn\u00ed operace.<\/p>\n<p>Vych\u00e1z\u00ed-li recidiva z fossa poplitea, preparace je obt\u00ed\u017en\u011bj\u0161\u00ed jednak vzhledem k t\u011bsn\u00e9mu vztahu VSP k okoln\u00edm struktur\u00e1m (a. et v. poplitea, n. tibialis), jednak pro variabilitu \u00fast\u00ed VSP do VP. D\u016fle\u017eit\u00e9 je spr\u00e1vn\u00e9 um\u00edst\u011bn\u00ed ko\u017en\u00edho \u0159ezu, nejl\u00e9pe na podklad\u011b p\u0159edopera\u010dn\u00edho ultrazvukov\u00e9ho vy\u0161et\u0159en\u00ed. \u00dast\u00ed-li VSP v\u00fd\u0161e, m\u016f\u017eeme si pomoci flex\u00ed v kolenn\u00edm kloubu. T\u00edm se incize posune krani\u00e1ln\u011bji.<\/p>\n<p>VSP, resp. jej\u00ed ponechan\u00fd pah\u00fdl, vypreparujeme a\u017e k \u00fast\u00ed do VP a zde jej ligujeme. Vych\u00e1z\u00ed-li z pah\u00fdlu VSP v\u011btev, b\u011b\u017e\u00edc\u00ed podko\u017en\u011b k VSM, m\u016f\u017eeme ji vystripovat. Zav\u00e1d\u011bn\u00ed sondy kontrolujeme vizu\u00e1ln\u011b i palpac\u00ed, abychom si byli jisti jej\u00edm epifasci\u00e1ln\u00edm pr\u016fb\u011bhem.<\/p>\n<h5>10.4.3.2 Chirurgie hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu<\/h5>\n<h6>10.4.3.2.1 Rekonstrukce hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu<\/h6>\n<p><strong>10.4.3.2.1.1 Rekonstrukce pro uz\u00e1v\u011bry<\/strong><\/p>\n<p>Rekonstrukce jsou indikov\u00e1ny, jestli\u017ee p\u0159edch\u00e1zela alespo\u0148 ro\u010dn\u00ed intenzivn\u00ed konzervativn\u00ed terapie, kter\u00e1 nedok\u00e1\u017ee zabr\u00e1nit zhor\u0161ov\u00e1n\u00ed stavu a pacient je v\u00fdznamn\u011b omezov\u00e1n.<\/p>\n<h6>UZ\u00c1V\u011aR SPOLE\u010cN\u00c9 P\u00c1NEVN\u00cd V\u00c9NY (PALMOVA OPERACE)<\/h6>\n<p>Operace je indikov\u00e1na, je-li uzav\u0159ena jen spole\u010dn\u00e1 a zevn\u00ed p\u00e1nevn\u00ed tepna bez trombotick\u00fdch zm\u011bn pod t\u0159\u00edseln\u00fdm vazem a je-li pacient sv\u00fdm onemocn\u011bn\u00edm v\u00fdrazn\u011b omezov\u00e1n. Velk\u00e1 safena druh\u00e9 strany je suprapubicky vedena na druhou stranu a na\u0161ita end to side na vhodnou \u017e\u00edlu v t\u0159\u00edsle \u2013 v. femoralis, safenofemor\u00e1ln\u00ed junkci nebo na v. femoralis superficialis. Inkompetence pou\u017eit\u00e9 velk\u00e9 safeny nebr\u00e1n\u00ed jej\u00edmu pou\u017eit\u00ed. Nen\u00ed-li VSM na druh\u00e9 stran\u011b, je mo\u017eno pou\u017e\u00edt stejnostrannou, ale reverzn\u011b nebo po valvulotomii.<\/p>\n<p>Dal\u0161\u00ed mo\u017enost\u00ed je pou\u017e\u00edt PTFE prot\u00e9zu jdouc\u00ed pod t\u0159\u00edslem, pod svaly preperitone\u00e1ln\u011b, a anastom\u00f3zovat ji end to side s v. iliaca externa. Prot\u00e9za by m\u011bla m\u00edt\u00a08 mm v pr\u016fm\u011bru a m\u011bla by b\u00fdt opat\u0159ena krou\u017eky, aby nedo\u0161lo k jej\u00edmu stla\u010den\u00ed. Doporu\u010duje se zalo\u017een\u00ed A-V p\u00ed\u0161t\u011ble za pomoci v\u011btve VSM na dobu 3 m\u011bs\u00edc\u016f .<\/p>\n<h6>POST TROMBOTICK\u00dd UZ\u00c1V\u011aR VENA<\/h6>\n<h6>FEMORALIS SUPERFICIALIS (MAY-HUSNI OPERACE)<\/h6>\n<p>P\u0159i t\u00e9to operaci vyu\u017eijeme VSM. Protneme ji a spoj\u00edme s v. poplitea nad nebo pod kolenem. Jsou mo\u017en\u00e9 dva zp\u016fsoby rekonstrukce:<\/p>\n<ol>\n<li>end to side,<\/li>\n<li>end to end \u2013 po prot\u011bt\u00ed v. poplitea.<\/li>\n<\/ol>\n<h6>10.4.3.2.1.2 Rekonstrukce pro inkompetenci vena poplitea a vena femoralis superficialis<\/h6>\n<p><strong>Z\u00e1kladn\u00edm principem l\u00e9\u010dby je eliminovat reflux v hlubok\u00e9m \u017eiln\u00edm syst\u00e9mu.<\/strong><\/p>\n<p>Transpozice hlubok\u00e9 femor\u00e1ln\u00ed \u017e\u00edly do sousedn\u00ed \u017e\u00edly s chlopn\u011bmi<\/p>\n<p>Transpozice je indikov\u00e1na sp\u00ed\u0161e u posttrombotick\u00fdch stav\u016f, kdy jsou chlopn\u011b destruov\u00e1ny flebitick\u00fdm procesem a valvuloplastika ned\u00e1v\u00e1 tak dobr\u00e9 v\u00fdsledky jako u prim\u00e1rn\u00ed insuficience. P\u0159i v\u00fdznamn\u00e9m refluxu v d\u016fsledku inkompetence VP a VFS, nen\u00ed-li p\u0159\u00edtomna obstrukce, je mo\u017eno pou\u017e\u00edt chlopn\u011b ve VFP nebo v jejich v\u011btv\u00edch, p\u0159\u00edpadn\u011b i v horn\u00ed \u010d\u00e1sti VSM.<\/p>\n<p>P\u0159i p\u0159edopera\u010dn\u00edm vy\u0161et\u0159en\u00ed je nutno chlopn\u011b lokalizovat a zjistit jejich kompetenci.<br \/>\nVy\u00fast\u011bn\u00ed VFS je transponov\u00e1no na VSM nebo VPF. Jsou-li ob\u011b kompetentn\u00ed, pak je lep\u0161\u00ed VSM. Existence \u0161irok\u00e9 komunikace mezi inkompetentn\u00ed VFP a VP je kontraindikac\u00ed k transplantaci ven\u00f3zn\u00edho segmentu s chlopn\u00ed na \u00farovni VFS nebo k transpozici VFS na VSM.<\/p>\n<p>Autotransplantace segmentu v\u00e9ny s chlopn\u00ed (Taheri)<\/p>\n<p>Pro tuto rekonstrukci plat\u00ed stejn\u00e1 indikace jako pro\u00a0p\u0159edchoz\u00ed, tj. v\u00fdznamn\u00e1 inkompetence VP a VFS zp\u016fsoben\u00e1 p\u0159edchoz\u00ed tromb\u00f3zou nebo deficitem chlopn\u00ed.\u00a0Zdrojem je v. axillaris, v. brachialis nebo horn\u00ed \u010d\u00e1st\u00a0druhostrann\u00e9 VSM.<\/p>\n<p>Valvuloplastika<\/p>\n<ol>\n<li><strong>Vnit\u0159n\u00ed<br \/>\n<\/strong>U Kistnerovy operace se vyberou p\u0159i flebografii\u00a0vhodn\u00e9 chlopn\u011b, zp\u0159\u00edstupn\u00ed se flebotomi\u00ed, p\u0159i kter\u00e9\u00a0nesm\u00ed b\u00fdt po\u0161kozeny jejich c\u00edpy, a stehy se nalo\u017e\u00ed\u00a0na ka\u017ed\u00fd konec chlopn\u00ed s c\u00edlem zkr\u00e1tit nadbyte\u010dn\u00e9 okraje c\u00edp\u016f a dos\u00e1hnout symetrie. V\u00e9na je pak\u00a0uzav\u0159ena a kompetence chlopn\u011b se ov\u011b\u0159\u00ed tak, \u017ee se\u00a0nejd\u0159\u00edve povol\u00ed horn\u00ed svorka a pozoruje se, je-li segment pod chlopn\u00ed pr\u00e1zdn\u00fd.\u00a0Raju a Sottiurai modifikovali p\u016fvodn\u00ed Kistnerovu\u00a0metodu a prov\u00e1d\u011bj\u00ed vnit\u0159n\u00ed plastiku ze upravalvul\u00e1rn\u00ed venotomie.Nev\u00fdhodou metody je jej\u00ed \u010dasov\u00e1 n\u00e1ro\u010dnost a obt\u00ed\u017en\u00e1 proveditelnost u \u017eil mal\u00e9ho pr\u016fsvitu. V takov\u00e9m p\u0159\u00edpad\u011b jsou vhodn\u011bj\u0161\u00ed metody jako zevn\u00ed\u00a0valvuloplastika nebo l\u00edmec in situ, kter\u00e9 jsou rychle\u00a0provediteln\u00e9 a nevy\u017eaduj\u00ed venotomii.<\/li>\n<li><strong>Zevn\u00ed<br \/>\n<\/strong>Metodu popsal Kistner v roce 1990. Jde o obnoven\u00ed funkce chlopn\u011b nalo\u017een\u00edm steh\u016f v pod\u00e9ln\u00e9 ose v\u00e9ny v m\u00edst\u011b \u00faponu c\u00edp\u016f chlopn\u011b. Nen\u00ed nutn\u00e1 venotomie, je men\u0161\u00ed traumatizace \u017eiln\u00ed st\u011bny. Metoda je rychl\u00e1, av\u0161ak nep\u0159esn\u00e1. Zu\u017euje chlopenn\u00ed sinus, ale nekoriguje nadbyte\u010dn\u00e9 c\u00edpy chlopn\u00ed.<\/li>\n<li><strong>Valvuloplastika za pou\u017eit\u00ed angioskopu<br \/>\n<\/strong>Spojuje v\u00fdhody zevn\u00ed a vnit\u0159n\u00ed metody. Valvuloplastika je realizov\u00e1na bez venotomie za p\u0159\u00edm\u00e9 kontroly zrakem pomoc\u00ed angioskopu. Ten je zaveden\u00a0p\u0159es VSM nebo jej\u00ed v\u011btev a\u017e do oblasti bifurkace VF.\u00a0Nakl\u00e1d\u00e1n\u00ed steh\u016f je nav\u00edc usnadn\u011bno prosv\u00edcen\u00edm\u00a0\u017eiln\u00ed st\u011bny sv\u011btlem angioskopu. Po zhotoven\u00ed plastiky je provedena kontrola kompetence chlopn\u011b irigac\u00ed kan\u00e1lem angioskopu. Pot\u00e9 je aplikov\u00e1n l\u00edmec\u00a0z PTFE kolem plastiky s c\u00edlem zabr\u00e1nit pozd\u011bj\u0161\u00ed\u00a0dilataci a n\u00e1sledn\u00e9 sekund\u00e1rn\u00ed inkompetenci.<\/li>\n<\/ol>\n<p>Konstrukce zevn\u00ed poplite\u00e1ln\u00ed chlopn\u011b (Psathakis) Tento postup u\u017e\u00edv\u00e1 silastikovou smy\u010dku p\u0159ipevn\u011bnou k flexor\u016fm kolene um\u00edst\u011bnou kolem poplite\u00e1ln\u00ed v\u00e9ny. Z\u00e1m\u011brem je sta\u017een\u00ed kli\u010dky kolem v\u00e9ny, a t\u00edm zabr\u00e1n\u011bn\u00ed refluxu v n\u00ed v okam\u017eiku kontrakce flexor\u016f, kdy\u017e se noha zved\u00e1 ze zem\u011b p\u0159i ka\u017ed\u00e9m kroku.<\/p>\n<p>V origin\u00e1ln\u00ed operaci byla u\u017eita \u0161lacha m. gracilis, odd\u011blen\u00e1 dist\u00e1ln\u011b a p\u0159ipojen\u00e1 nap\u0159\u00ed\u010d p\u0159es fossa poplitea k m. biceps femoris. Pozd\u011bji byla pou\u017eita silastikov\u00e1 smy\u010dka. Operace se neujala.<\/p>\n<p>K rekonstrukci chlopn\u00ed je indikov\u00e1no jen velmi m\u00e1lo pacient\u016f v pokro\u010dil\u00fdch stadi\u00edch chronick\u00e9 ven\u00f3zn\u00ed insuficience, kde jin\u00e1 terapie selhala. Nelze prov\u00e1d\u011bt rekonstrukci, jsou-li \u017e\u00edly nad a pod m\u00edstem insuficience tak\u00e9 t\u011b\u017ece po\u0161kozeny. Je rovn\u011b\u017e m\u00e1lo pravd\u011bpodobn\u00e9, \u017ee interpozice jedn\u00e9 nebo dvou chlopn\u00ed p\u0159inese velk\u00e9 zm\u011bny u stavu s pov\u0161echnou chlopenn\u00ed insuficienc\u00ed.<\/p>\n<h6>VEN\u00d3ZN\u00cd TROMBEKTOMIE<\/h6>\n<p>Prvn\u00ed trombektomii pro ileofemor\u00e1ln\u00ed \u017eiln\u00ed tromb\u00f3zu provedl v roce 1937 Lawen. Chirurgick\u00e1 l\u00e9\u010dba hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy v\u0161ak nedoznala v\u011bt\u0161\u00edho roz\u0161\u00ed\u0159en\u00ed, i kdy\u017e spr\u00e1vn\u011b indikovan\u00e1 m\u00e1 sv\u00e9 p\u0159ednosti. Je jednak prevenc\u00ed fat\u00e1ln\u00ed embolizace do plic, jednak posttrombotick\u00e9ho syndromu, nebo\u0165 zachov\u00e1v\u00e1 norm\u00e1ln\u00ed funkci chlopn\u00ed a pr\u016fchodnost v\u00e9n.<\/p>\n<h6>Chirurgick\u00e1 l\u00e9\u010dba<\/h6>\n<p>Pacienta ulo\u017e\u00edme do anti-Trendelenburgovy polohy.\u00a0Z pod\u00e9ln\u00e9 incize v t\u0159\u00edsle vyhled\u00e1me za pomoci VSM\u00a0stehenn\u00ed v\u00e9nu a vedeme p\u0159\u00ed\u010dnou nebo \u0161ikmou venotomii. V\u00fdkon prov\u00e1d\u00edme za celkov\u00e9 heparinizace. Krv\u00e1cen\u00ed kontrolujeme pouze tlakem tamponu, sna\u017e\u00edme\u00a0se nepou\u017e\u00edvat kovov\u00e9 svorky. Zavedeme Fogartyho\u00a0kat\u00e9tr nad trombus, kat\u00e9tr nafoukneme a trombus\u00a0st\u00e1hneme. Cel\u00fd proces opakujeme, a\u017e nez\u00edsk\u00e1me \u017e\u00e1dn\u00fd trombotick\u00fd materi\u00e1l. Zp\u011btn\u00fd tok nen\u00ed spolehlivou zn\u00e1mkou odstran\u011bn\u00ed trombu. M\u016f\u017ee b\u00fdt vydatn\u00fd p\u0159i pr\u016fchodn\u00e9 vnit\u0159n\u00ed ilick\u00e9 v\u00e9n\u011b. Proto prov\u00e1d\u00edme kontroln\u00ed flebografii. Z periferie odstra\u0148ujeme trombus kombinac\u00ed Fogartyho man\u00e9vru a manu\u00e1ln\u00ed komprese kon\u010detiny. Nav\u00edc p\u0159ikl\u00e1d\u00e1me elastick\u00e9 obinadlo od periferie sm\u011brem centr\u00e1ln\u00edm. Sna\u017e\u00edme se tak odstranit tromby z v\u011btv\u00ed trombozovan\u00e9 v\u00e9ny. Proces komprese opakujeme, a\u017e z periferie nelze odstranit \u017e\u00e1dn\u00e9 tromby. Venotomii uzav\u00edr\u00e1me monofilamentn\u00edm vl\u00e1knem, n\u011bkte\u0159\u00ed auto\u0159i doporu\u010duj\u00ed zalo\u017eit do\u010dasnou arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011bl za pomoci pro\u0165at\u00e9 VSM, jej\u00ed\u017e konec anastom\u00f3zuj\u00ed ke stran\u011b povrchov\u00e9 stehenn\u00ed tepny. P\u00ed\u0161t\u011bl ru\u0161\u00ed za 6 t\u00fddn\u016fP\u0159i posti\u017een\u00ed i VCI je mo\u017eno trombus odstranit p\u0159\u00edmo z dut\u00e9 \u017e\u00edly, bu\u010f transperitone\u00e1ln\u00ed nebo extraperitone\u00e1ln\u00ed cestou ze subkost\u00e1ln\u00edho \u0159ezu. Po mobilizaci colon ascendens a duodena nasad\u00edme na VCI svorku pod ren\u00e1ln\u00edmi v\u00e9nami. Z kavotomie odstran\u00edme trombus a kavotomii uzav\u0159eme. V poopera\u010dn\u00edm obdob\u00ed je pacient heparinizov\u00e1n, pot\u00e9 n\u00e1sleduje warfarinizace na dobu 6 m\u011bs\u00edc\u016f.\u00a0Pln\u00e9 rozvinut\u00ed posttrombotick\u00e9ho syndromu trv\u00e1 \u0159adu let, proto prvn\u00ed hodnocen\u00ed \u00fasp\u011b\u0161nosti trombektomie m\u016f\u017eeme prov\u00e9st nejd\u0159\u00edve za 5\u201310 let.<\/p>\n<p>Dominantn\u00edm postupem u akutn\u00ed ileofemor\u00e1ln\u00ed tromb\u00f3zy je fibrinolytick\u00e1 l\u00e9\u010dba.<\/p>\n<h6>KOMPRESIVN\u00cd SKLEROTIZACE<\/h6>\n<p>Kompresivn\u00ed skleroterapie je efektivn\u00ed a bezpe\u010dn\u00e1 metoda v l\u00e9\u010db\u011b varix\u016f doln\u00edch kon\u010detin. Je rychl\u00e1, nevy\u017eaduje hospitalizaci ani pracovn\u00ed neschopnost a d\u00e1 se opakovat. Je v\u0161ak t\u0159eba dodr\u017eet indikace a m\u00edt s metodou dostatek vlastn\u00edch zku\u0161enost\u00ed. Stejn\u011b jako v\u0161echny ostatn\u00ed postupy pou\u017e\u00edvan\u00e9 v terapii varix\u016f, v\u010detn\u011b chirurgie, jedn\u00e1 se o l\u00e9\u010dbu paliativn\u00ed, ne etiologickou.<\/p>\n<p>P\u0159ed ka\u017edou skerotizac\u00ed je nutno pacienta vy\u0161et\u0159it jak klinicky, tak duplexn\u00ed ultrasonografi\u00ed k vylou\u010den\u00ed insuficience \u00fast\u00ed VSM a VSP. Jsou-li tato \u00fast\u00ed insuficientn\u00ed, pak je nad\u011bje na trval\u00fd \u00fasp\u011bch sklerotizace nepatrn\u00e1. Je mo\u017eno dos\u00e1hnout uz\u00e1v\u011bru v\u00e9ny, av\u0161ak v pr\u016fb\u011bhu n\u011bkolika let dojde k rekanalizaci. Proto je v takov\u00e9m p\u0159\u00edpad\u011b indikov\u00e1na l\u00e9\u010dba chirurgick\u00e1.<br \/>\nIndikace:<\/p>\n<ul>\n<li>odstran\u011bn\u00ed subjektivn\u00edch pot\u00ed\u017e\u00ed,<\/li>\n<li>zabr\u00e1n\u011bn\u00ed komplikac\u00edm,<\/li>\n<li>kosmetick\u00e9 hledisko.<\/li>\n<\/ul>\n<p>Kontraindikace:<\/p>\n<ul>\n<li>alergie na sklerotiza\u010dn\u00ed l\u00e1tku,<\/li>\n<li>hlubok\u00e1 \u017eiln\u00ed tromb\u00f3za,<\/li>\n<li>celkov\u00e1 nebo m\u00edstn\u00ed infekce,<\/li>\n<li>kritick\u00e1 ischemie doln\u00edch kon\u010detin,<\/li>\n<li>otoky doln\u00edch kon\u010detin,<\/li>\n<li>nemo\u017enost nalo\u017eit kompresivn\u00ed obvaz,<\/li>\n<li>imobiln\u00ed pacient,<\/li>\n<li>hyperkoagulabilita (deficit proteinu C a S),<\/li>\n<li>angiodysplazie (Klippel-Tr\u00e9naunaysy), kdy jsou p\u0159\u00edtomny A-V p\u00ed\u0161t\u011ble,<\/li>\n<li>gravidita.<\/li>\n<\/ul>\n<p>Mal\u00e9 varixy (retikul\u00e1rn\u00ed a teleangiekt\u00e1zie)<\/p>\n<p>V l\u00e9\u010db\u011b mal\u00fdch varix\u016f m\u00e1 sklerotizace dominantn\u00ed\u00a0postaven\u00ed. Indikace je v\u011bt\u0161inou kosmetick\u00e1, i kdy\u017e\u00a0i tyto varixy mohou p\u016fsobit pot\u00ed\u017ee, zejm\u00e9na v obdob\u00ed\u00a0menstruace. Je v\u0161ak nutno vylou\u010dit sou\u010dasn\u00e9 posti\u017een\u00ed\u00a0skryt\u00fdch \u017eil.<\/p>\n<p>Velk\u00e9 nekmenov\u00e9 varixy (perfor\u00e1tory, varixy v povod\u00ed p\u0159\u00edtok\u016f, lok\u00e1ln\u00ed varixy a recidivuj\u00edc\u00ed varixy) Sklerotizace je indikovan\u00e1 po d\u016fkladn\u00e9m vy\u0161et\u0159en\u00ed, zejm\u00e9na u recidivuj\u00edc\u00edch varix\u016f. Je mo\u017en\u00e1 jak chirurgick\u00e1, tak sklerotiza\u010dn\u00ed l\u00e9\u010dba. Z\u00e1le\u017e\u00ed na zku\u0161enosti l\u00e9ka\u0159e a velikosti varix\u016f. Stran perfor\u00e1tor\u016f nen\u00ed jednotn\u00fd n\u00e1zor na sklerotizaci, my sami se p\u0159ikl\u00e1n\u00edme k l\u00e9\u010db\u011b chirurgick\u00e9.<\/p>\n<p>Kmenov\u00e9 varixy VSM<\/p>\n<p>Nen\u00ed jednotn\u00fd n\u00e1zor, zda varixy v povod\u00ed velk\u00e9 safeny\u00a0sklerotizovat \u010di operovat. Pokud se rozhodneme pro\u00a0sklerotizaci, mus\u00edme po\u010d\u00edtat s vysok\u00fdm procentem\u00a0recidivy, kter\u00e9 je vy\u0161\u0161\u00ed ne\u017e u pacient\u016f l\u00e9\u010den\u00fdch chirurgicky. Na na\u0161em pracovi\u0161ti pova\u017eujeme kmenov\u00e9\u00a0varixy v povod\u00ed VSM za indikaci k operaci a sklerotizaci zde neprov\u00e1d\u00edme, a to ani pod kontrolou ultrazvukem. I kdy\u017e je pacient star\u00fd nebo ne zcela v dobr\u00e9m stavu, je mo\u017eno operovat ve spin\u00e1ln\u00ed anestezii\u00a0nebo v lok\u00e1ln\u00ed anestezii prov\u00e9st krosektomii VSM\u00a0s n\u00e1slednou sklerotizac\u00ed.<\/p>\n<p>Kmenov\u00e9 varixy VSP<\/p>\n<p>Ani zde nepanuje jednotn\u00fd n\u00e1zor, zav\u00eds\u00ed i na \u0161\u00ed\u0159ce insuficientn\u00edho \u00fast\u00ed VSP do v. poplitea a velikosti refluxu. Up\u0159ednost\u0148ujeme chirurgick\u00e9 \u0159e\u0161en\u00ed.<\/p>\n<p>Je n\u011bkolik technik sklerotizace:<\/p>\n<ol>\n<li>\u0161v\u00fdcarsk\u00e1 \u2013 Sigg: sklerotizuje se z periferie sm\u011brem\u00a0centr\u00e1ln\u00edm bez ohledu na m\u00edsto refluxu. Varix je\u00a0punktov\u00e1n u stoj\u00edc\u00edho nemocn\u00e9ho, k aplikaci sklerotiza\u010dn\u00edho roztoku doch\u00e1z\u00ed a\u017e po jeho ulo\u017een\u00ed\u00a0do horizont\u00e1ln\u00ed polohy;<\/li>\n<li>francouzsk\u00e1 \u2013 Tournay: postupuje sm\u011brem opa\u010dn\u00fdm ne\u017e \u0161v\u00fdcarsk\u00e1 technika, tj. z proxim\u00e1ln\u00edch parti\u00ed dist\u00e1ln\u011b. Obliterac\u00ed proxim\u00e1ln\u00edch \u017eil se sna\u017e\u00ed sn\u00ed\u017eit hydrostatick\u00fd tlak v dist\u00e1ln\u00edch v\u00e9n\u00e1ch a urychlit\u00a0tak proces jejich fibrotizace. Punkce i sklerotizace jsou prov\u00e1d\u011bny v horizont\u00e1ln\u00ed poloze;<\/li>\n<li>irsk\u00e1 \u2013 Fegan: hlavn\u00ed p\u0159\u00ed\u010dinu varix\u016f vid\u00ed v inkompetentn\u00edch perfor\u00e1torech, kter\u00e9 sklerotizuje.<\/li>\n<li>sklerotizace pod kontrolou ultrazvukem. P\u0159i tomto postupu je aplikace sklerotiza\u010dn\u00ed l\u00e1tky kontrolov\u00e1na ultrazvukem. Pou\u017e\u00edv\u00e1 se ke sklerotizaci \u00fast\u00ed VSM, ke sklerotizaci perfor\u00e1tor\u016f nebo u ob\u00e9zn\u00edch pacient\u016f, kde je detekce varix\u016f obt\u00ed\u017en\u00e1. I zast\u00e1nci t\u00e9to metody ud\u00e1vaj\u00ed hor\u0161\u00ed v\u00fdsledky, je-li pr\u016fm\u011br VSM v\u011bt\u0161\u00ed ne\u017e 20 mm. Chyb\u00ed dlouhodob\u00e9 v\u00fdsledky.<\/li>\n<\/ol>\n<p>C\u00edlem sklerotizace je eliminovat patologick\u00fd reflux a viditeln\u00e9 varixy.<\/p>\n<p>Sklerotizaci prov\u00e1d\u00edme vle\u017ee, i kdy\u017e \u0159ada flebolog\u016f aplikuje sklerotiza\u010dn\u00ed l\u00e1tku stoj\u00edc\u00edmu pacientovi. Poloha vle\u017ee nebo s m\u00edrnou elevac\u00ed kon\u010detiny je pro pacienta p\u0159\u00edzniv\u011bj\u0161\u00ed a dojde p\u0159i n\u00ed k vypr\u00e1zdn\u011bn\u00ed \u017eil (technika pr\u00e1zdn\u00e9 \u017e\u00edly). To m\u00e1 za n\u00e1sledek lep\u0161\u00ed kontakt \u017eiln\u00ed st\u011bny se sklerotiza\u010dn\u00edm roztokem, ne\u017e je tomu u krv\u00ed napln\u011bn\u00e9ho varixu vestoje. Aplikac\u00ed kompresivn\u00ed band\u00e1\u017ee ihned po sklerotizaci, je\u0161t\u011b u le\u017e\u00edc\u00edho pacienta, zaji\u0161\u0165ujeme zachov\u00e1n\u00ed pr\u00e1zdn\u00e9 v\u00e9ny. Nen\u00ed-li \u017e\u00edla pr\u00e1zdn\u00e1, vytv\u00e1\u0159\u00ed se trombus, kter\u00fd postupn\u011b rekanalizuje a doch\u00e1z\u00ed tak k recidiv\u011b. Nav\u00edc b\u00fdv\u00e1 bolestiv\u00fd a kosmeticky ru\u0161iv\u00fd. D\u0159\u00edve u\u017e\u00edvan\u00e1 <i>\u201eair\u00a0<\/i>\u2013 bolus\u201c nebo \u201eair \u2013 block\u201c technika je nyn\u00ed ji\u017e opu\u0161t\u011bna. Spo\u010d\u00edvala v aplikaci vzduchu p\u0159ed sklerotiza\u010dn\u00edm agens s c\u00edlem vypr\u00e1zdnit v\u00e9nu, a umo\u017enit tak kontakt l\u00e1tky se st\u011bnou. Radiologick\u00e9 studie ale prok\u00e1zaly, \u017ee injekce vzduchu do VSM nezajist\u00ed odstran\u011bn\u00ed krve, a to ani p\u0159i aplikaci 0,5 ml vzduchu. Foam sklerotizace je aplikace sklerotiza\u010dn\u00ed l\u00e1tky ve form\u011b p\u011bny. Ta se p\u0159iprav\u00ed opakovan\u00fdm rychl\u00fdm p\u0159esunem roztoku sklerotiza\u010dn\u00edho agens pod tlakem mezi dv\u011bma spojen\u00fdmi injek\u010dn\u00edmi st\u0159\u00edka\u010dkami. V\u00fdhodou p\u011bny by m\u011blo b\u00fdt del\u0161\u00ed p\u016fsoben\u00ed agens na \u017eiln\u00ed st\u011bnu, ne\u017e je tomu u b\u011b\u017en\u00e9ho roztoku, kter\u00fd je rychle odplaven. Sklerotiza\u010dn\u00ed roztok ve form\u011b p\u011bny m\u00e1 v\u011bt\u0161\u00ed objem, sni\u017euje se tak jeho mno\u017estv\u00ed pot\u0159ebn\u00e9 ke sklerotizaci. Aplikaci p\u011bny m\u016f\u017eeme snadno sledovat pod kontrolou ultrazvukem, proto\u017ee je \u010d\u00e1ste\u010dn\u011b echogenn\u00ed.<\/p>\n<p>Tam, kde je punkce varixu obt\u00ed\u017en\u00e1, m\u016f\u017eeme ji prov\u00e9st vestoje a pot\u00e9 pacienta polo\u017eit do horizont\u00e1ln\u00ed polohy. K tomu \u00fa\u010delu jsou zhotoveny speci\u00e1ln\u00ed polohovac\u00ed stoly. Tento postup nen\u00ed vhodn\u00fd u mal\u00fdch \u017eil, kde je nebezpe\u010d\u00ed dislokace jehly a n\u00e1sledn\u00e9ho paraven\u00f3zn\u00edho pod\u00e1n\u00ed l\u00e1tky.<\/p>\n<p>Po aplikaci p\u0159ikl\u00e1d\u00e1me nad sklerotizovanou v\u00e9nu pod\u00e9ln\u011b longetu a n\u00e1sledn\u011b kompresivn\u00ed obvaz. C\u00edlem komprese po sklerotizaci do vypr\u00e1zdn\u011bn\u00e9 v\u00e9ny je z\u00fa\u017eit \u017e\u00edlu co mo\u017en\u00e1 nejv\u00edce, a zabr\u00e1nit tak vzniku intravaskul\u00e1rn\u00edch tromb\u016f, kter\u00e9 mohou zp\u016fsobit z\u00e1n\u011bt a \u010dasnou rekanalizaci. Doba komprese kol\u00eds\u00e1 dle jednotliv\u00fdch autor\u016f mezi 3 a\u017e 6 t\u00fddny. Klasicky byla doporu\u010dov\u00e1na komprese na dobu 6 t\u00fddn\u016f, v sou\u010dasnosti se v\u011bt\u0161ina klon\u00ed k t\u0159\u00edt\u00fddenn\u00ed kompresi po sklerotizaci. Komprese je od\u016fvodn\u011bn\u00e1 i u l\u00e9\u010dby teleangiekt\u00e1zi\u00ed, kdy sni\u017euje v\u00fdskyt pigmentac\u00ed i perimaleol\u00e1rn\u00edch a l\u00fdtkov\u00fdch otok\u016f. Pacientovi doporu\u010dujeme dostate\u010dnou pohybovou aktivitu.<\/p>\n<p>Chirurgickou l\u00e9\u010dbu a sklerotizaci nepova\u017eujeme za metody navz\u00e1jem si konkuruj\u00edc\u00ed, ale sp\u00ed\u0161e se dopl\u0148uj\u00edc\u00ed. Drobn\u00e9 varixy lze s \u00fasp\u011bchem odstranit sklerotizac\u00ed a u\u0161et\u0159it pacienta operace, by\u0165 v lok\u00e1ln\u00ed anestezii a v r\u00e1mci jednodenn\u00ed chirurgie. Na stran\u011b druh\u00e9 insuficienci \u00fast\u00ed safen je vhodn\u00e9 \u0159e\u0161it chirurgicky a drobn\u00e9 retikul\u00e1rn\u00ed varixy eliminovat sklerotizac\u00ed v poopera\u010dn\u00edm obdob\u00ed.<\/p>\n<h6>Komplikace sklerotizace<\/h6>\n<p>C\u00edlem sklerotizace je chemick\u00e9 posti\u017een\u00ed st\u011bny \u017eiln\u00ed\u00a0s jej\u00ed n\u00e1slednou fibrotizac\u00ed. Toto toxick\u00e9 p\u016fsoben\u00ed ale\u00a0nen\u00ed specifick\u00e9 jen na \u017eiln\u00ed st\u011bnu, m\u016f\u017ee doj\u00edt k po\u0161kozen\u00ed okoln\u00edch struktur. Doch\u00e1z\u00ed k tomu p\u0159i aplikaci sklerotiza\u010dn\u00ed l\u00e1tky paraven\u00f3zn\u011b, nebo dokonce\u00a0intraarteri\u00e1ln\u011b. Komplikace ale mohou nastat i p\u0159i\u00a0intraven\u00f3zn\u00ed aplikaci, z\u00e1vis\u00ed na mno\u017estv\u00ed a koncentraci roztoku.<\/p>\n<ul>\n<li><strong>Bolest<\/strong> \u2013 v m\u00edst\u011b aplikace sklerotiza\u010dn\u00edho roztoku.P\u0159\u00ed\u010dinou b\u00fdv\u00e1 paraven\u00f3zn\u00ed aplikace s n\u00e1sledn\u00fdm\u00a0toxick\u00fdm po\u0161kozen\u00edm nervu.<\/li>\n<li><strong>Povrchov\u00e1 flebitis<\/strong> \u2013 vznik\u00e1 p\u0159i aplikaci do nevypr\u00e1zdn\u011bn\u00e9 v\u00e9ny, p\u0159i aplikaci p\u0159\u00edli\u0161 velk\u00e9ho mno\u017estv\u00ed roztoku nebo nep\u0159im\u011b\u0159en\u00e9 koncentrace. Pod\u00edl\u00ed\u00a0se i nedostate\u010dn\u00e1 komprese. Intravarik\u00f3zn\u00ed koagulum b\u00fdv\u00e1 bolestiv\u00e9 a kosmeticky ru\u0161iv\u00e9. Terapie\u00a0spo\u010d\u00edv\u00e1 v jeho aspiraci st\u0159\u00edka\u010dkou nebo v evakuaci\u00a0po punkci jehlou \u010di skalpelem. Z\u00e1n\u011btliv\u00fd proces\u00a0m\u016f\u017ee p\u0159esahovat i na okoln\u00ed tk\u00e1n\u011b a v\u00e9st k tzv. artefici\u00e1ln\u00ed periflebitid\u011b.<\/li>\n<li><strong>Nekr\u00f3za<\/strong> \u2013 je zap\u0159\u00ed\u010din\u011bna aplikac\u00ed sklerotiza\u010dn\u00edho roztoku paraven\u00f3zn\u011b, do rterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble, rupturou st\u011bny varixu, zejm\u00e9na p\u0159i aplikaci\u00a0pod velk\u00fdm tlakem, nebo p\u0159i sklerotizaci v m\u00e9n\u011b\u00a0kvalitn\u00ed tk\u00e1ni. Rozsah nekr\u00f3zy z\u00e1vis\u00ed na mno\u017estv\u00ed\u00a0a koncentraci aplikovan\u00e9 l\u00e1tky. Polidocanol v koncentraci 0,25% je mo\u017eno aplikovat perivaskul\u00e1rn\u011b\u00a0u teleangiekt\u00e1zi\u00ed, kter\u00e9 nelze sklerotizovat intravaskul\u00e1rn\u011b. Jeho vy\u0161\u0161\u00ed koncentrace ale ji\u017e vedou\u00a0k nekr\u00f3z\u00e1m. Je-li tato komplikace zpozorov\u00e1na,\u00a0doporu\u010duje se aplikovat do posti\u017een\u00e9ho m\u00edsta\u00a0sm\u011bs lok\u00e1ln\u00edho anestetika a \u00a0yziologick\u00e9ho roztoku. V pr\u016fb\u011bhu jednoho a\u017e dvou t\u00fddn\u016f se vytvo\u0159\u00ed\u00a0krusta s okoln\u00edm eryt\u00e9mem. Samotn\u00e9 hojen\u00ed trv\u00e1\u00a0n\u011bkolik m\u011bs\u00edc\u016f a zanech\u00e1v\u00e1 hypopigmentovanou\u00a0jizvu. V dob\u011b hojen\u00ed je vhodn\u00e9 eliminovat slune\u010dn\u00ed\u00a0expozici, jinak hroz\u00ed hyperpigmentace. Jeliko\u017e je spont\u00e1nn\u00ed pr\u016fb\u011bh velmi zdlouhav\u00fd, je lep\u0161\u00ed nekr\u00f3zu excidovat.<\/li>\n<li><strong>Pigmentace<\/strong> \u2013 kosmeticky nep\u0159\u00edzniv\u00e1 komplikace, kter\u00e1 se zdlouhav\u011b hoj\u00ed v pr\u016fb\u011bhu mnoha m\u011bs\u00edc\u016f. V d\u016fsledku po\u0161kozen\u00ed \u017eiln\u00ed st\u011bny (ruptura n\u00e1sledkem vysok\u00e9ho tlaku injikovan\u00e9 l\u00e1tky, natr\u017een\u00ed jehlou) doch\u00e1z\u00ed k extravazaci. Vlastn\u00ed p\u0159\u00ed\u010dinou jsou depozita hemosiderinu. Jej\u00ed v\u00fdskyt se d\u00e1 omezit spr\u00e1vnou technikou. L\u00e9\u010dba je problematick\u00e1, nejlep\u0161\u00edch v\u00fdsledk\u016f dosahuje laser.<\/li>\n<li><strong>Dysestezie, hypestezie<\/strong> \u2013 jsou zp\u016fsobeny po\u0161kozen\u00edm ko\u017en\u00edho nervu p\u0159i sklerotizaci. Miz\u00ed do n\u011bkolika m\u011bs\u00edc\u016f. Z\u00e1va\u017en\u011bj\u0161\u00ed nebo trval\u00e9 l\u00e9ze jsou vz\u00e1cn\u00e9. Po\u0161kozen\u00ed motorick\u00fdch nerv\u016f p\u0159i sklerotizaci epifasci\u00e1ln\u00edch \u017eil je nepravd\u011bpodobn\u00e9.<\/li>\n<li><strong>Intraarteri\u00e1ln\u00ed aplikace<\/strong> \u2013 nejob\u00e1van\u011bj\u0161\u00ed komplikace s nep\u0159\u00edzniv\u00fdmi n\u00e1sledky. Vzhledem k mno\u017estv\u00ed proveden\u00fdch sklerotizac\u00ed a jen ojedin\u011bl\u00fdm kazuistik\u00e1m popisuj\u00edc\u00edm intra-arteri\u00e1ln\u00ed aplikaci se jedn\u00e1 o extr\u00e9mn\u011b vz\u00e1cnou komplikaci. Jej\u00ed nebezpe\u010d\u00ed hroz\u00ed p\u0159i sklerotizaci v t\u011bch oblastech, kde jsou arterie a v\u00e9na v t\u011bsn\u00e9 bl\u00edzkosti. To je oblast t\u0159\u00edsla (a. femoralis, a. pudenda externa), podkolenn\u00ed jamky (a. poplitea, a. suralis medialis et lateralis, vy\u017eivuj\u00edc\u00ed m. gastrocnemius), oblast vnit\u0159n\u00edho kotn\u00edku (a. tibialis posterior), oblast h\u0159betu nohy (a. dorsalis pedis) a zejm\u00e9na v okol\u00ed b\u00e9rcov\u00e9ho v\u0159edu, kdy je nebezpe\u010d\u00ed aplikace do a. tibialis posterior. Zn\u00e1mky intraarteri\u00e1ln\u00ed aplikace mohou b\u00fdt r\u016fzn\u00e9 \u2013 Oesch ud\u00e1v\u00e1 u v\u0161ech sv\u00fdch \u010dty\u0159 komplikac\u00ed n\u00e1hle vznikl\u00e9 siln\u00e9 bolesti, kter\u00e9 nepolevuj\u00ed, ba naopak, v noci zesiluj\u00ed. U v\u0161ech pacient\u016f byla l\u00e1tka aplikov\u00e1na v oblasti vnit\u0159n\u00edho kotn\u00edku. Bolest v\u011bt\u0161inou nast\u00e1v\u00e1 v pr\u016fb\u011bhu sklerotizace, je ohrani\u010dena na oblast dist\u00e1ln\u011b od m\u00edsta vpichu a je prov\u00e1zena zblednut\u00edm nebo cyan\u00f3zou periferie. Nastane-li tato situace, ponech\u00e1me jehlu in situ, odstran\u00edme st\u0159\u00edka\u010dku a podle charakteru vyt\u00e9kaj\u00edc\u00ed krve se p\u0159esv\u011bd\u010d\u00edme o tom, je-li jehla v tepn\u011b \u010di v\u00e9n\u011b. V prvn\u00edm p\u0159\u00edpad\u011b aplikujeme heparin a anestetikum (nap\u0159. mesocain) i v. zavedenou jehlou. Podm\u00ednkou je ov\u0161em rychl\u00e1 dostupnost heparinu v ambulanci a spolupr\u00e1ce pacienta, co\u017e p\u0159i intenzivn\u00ed bolesti nemus\u00ed b\u00fdt v\u017edy splniteln\u00e9. Kon\u010detinu ochlad\u00edme ledem k zamezen\u00ed tk\u00e1\u0148ov\u00e9 hypoxie a pacienta p\u0159ed\u00e1me do p\u00e9\u010de chirurga s c\u00e9vn\u00ed specializac\u00ed. N\u00e1sleduje heparinizace, p\u0159\u00edpadn\u011b fibrinolytick\u00e1 l\u00e9\u010dba. Terapie b\u00fdv\u00e1 dlouhodob\u00e1 a t\u00e9m\u011b\u0159 v\u017edy zanech\u00e1v\u00e1 n\u00e1sledky, jako p\u0159ecitliv\u011blost na chlad, amputace prst\u016f, nebo dokonce i v b\u00e9rci.<\/li>\n<li><strong>Alergick\u00e1 reakce na sklerotiza\u010dn\u00ed roztok<\/strong> je pom\u011brn\u011b vz\u00e1cn\u00e1. M\u016f\u017ee b\u00fdt m\u00edrn\u00e1, st\u0159edn\u00ed nebo t\u011b\u017ek\u00e1.P\u0159\u00edznaky m\u00edrn\u00e9 reakce jsou rush, urtika a sv\u011bd\u011bn\u00ed. Generalizovanou kop\u0159ivku je t\u0159eba odli\u0161it od lokalizovan\u00e9, kter\u00e1 se m\u016f\u017ee norm\u00e1ln\u011b objevit v m\u00edst\u011b vpichu v d\u016fsledku reakce endotelu na sklerozuj\u00edc\u00ed l\u00e1tku. St\u0159edn\u00ed reakce se m\u016f\u017ee projevit otokem laryngu se stridorem a s\u00edpotem n\u00e1sledkem bronchospazmu. U nejz\u00e1va\u017en\u011bj\u0161\u00ed alergick\u00e9 reakce doch\u00e1z\u00ed ke kardiovaskul\u00e1rn\u00edmu selh\u00e1n\u00ed v d\u016fsledku perifern\u00ed vazodilatace. L\u00e9\u010dba spo\u010d\u00edv\u00e1 v zaji\u0161t\u011bn\u00ed \u017eiln\u00ed linky, aplikaci adrenalinu, kortikoid\u016f a antihistaminik.<\/li>\n<li><strong>Hlubok\u00e1 \u017eiln\u00ed tromb\u00f3za a embolizace do a. pulmonalis<\/strong> \u2013 jsou komplikace velmi vz\u00e1cn\u00e9. P\u0159\u00ed\u010dina jejich vzniku po sklerotizaci nen\u00ed spolehliv\u011b objasn\u011bna. V prevenci je doporu\u010dov\u00e1no zredukovat mno\u017estv\u00ed sklerozuj\u00edc\u00edho agens maxim\u00e1ln\u011b na 1 ml na jeden vpich. T\u00edm se zabr\u00e1n\u00ed jeho pr\u016fniku do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu. V\u00fdznam m\u00e1 komprese a dostate\u010dn\u00e1 pohybov\u00e1 aktivita. Kritick\u00e9 obdob\u00ed pro vznik trombu je p\u0159ibli\u017en\u011b 9 hodin po sklerotizaci, proto m\u00e1 v\u00fdznam komprese noc po v\u00fdkonu.<\/li>\n<li><strong>Vzduchov\u00e1 embolie<\/strong> \u2013 teoreticky lze uva\u017eovat o mo\u017enosti vzduchov\u00e9 embolie p\u0159i pou\u017eit\u00ed air-block techniky nebo sklerotizace s agens ve form\u011b p\u011bny. Av\u0161ak tak mal\u00e1 mno\u017estv\u00ed vzduchu jsou rozpu\u0161t\u011bna v krvi d\u0159\u00edve, ne\u017e se dostanou do plicn\u00edho ob\u011bhu. Aby do\u0161lo ke smrteln\u00e9 vzduchov\u00e9 embolizaci, je t\u0159eba aplikovat do \u017eiln\u00edho syst\u00e9mu 480 ml vzduchu v pr\u016fb\u011bhu 20 a\u017e 30 sekund u osoby v\u00e1\u017e\u00edc\u00ed 60 kg.<\/li>\n<li>Vzhledem k mo\u017en\u00fdm komplikac\u00edm je nutno m\u00edt ve flebologick\u00e9 ambulanci k dispozici adrenalin, hydrokortison, antihistaminikum a prost\u0159edky pro endotrache\u00e1ln\u00ed intubaci.<\/li>\n<\/ul>\n<p>REHABILITA\u010cN\u00cd TERAPIE<\/p>\n<p>V d\u016fsledku chronick\u00e9 \u017eiln\u00ed insuficience v\u00e1zne \u017eiln\u00ed n\u00e1vrat. \u010c\u00e1st krve z doln\u00edch kon\u010detin nen\u00ed odv\u00e1d\u011bna zp\u011bt k srdci, ale refluktuje insuficientn\u00edmi body (SFJ, SPJ, perfor\u00e1tory). Doch\u00e1z\u00ed k p\u0159et\u011b\u017eov\u00e1n\u00ed \u017eiln\u011b-svalov\u00e9 pumpy, kter\u00e1 zv\u011bt\u0161en\u00fd objem krve nen\u00ed schopna transportovat.<br \/>\nFyzik\u00e1ln\u00ed terapie p\u0159in\u00e1\u0161\u00ed nemocn\u00e9mu \u00falevu. Vede k redukci nebo vymizen\u00ed ed\u00e9mu a pocitu t\u011b\u017ek\u00fdch nohou. M\u00e1 v\u00fdznam jak v terapii, tak v profylaxi \u017eiln\u00edch onemocn\u011bn\u00ed.<\/p>\n<p>Sedav\u00fd zp\u016fsob \u017eivota je faktor v\u00fdrazn\u011b zhor\u0161uj\u00edc\u00ed CVI. D\u016fle\u017eit\u00e1 je intermitentn\u00ed komprese plant\u00e1rn\u00edch \u017eil, kter\u00e1 p\u0159\u00edzniv\u011b ovliv\u0148uje \u017eiln\u00ed n\u00e1vrat sm\u011brem k srdci, stejn\u011b jako aktivn\u00ed pohyb v hlezenn\u00e9m ale i kolenn\u00edm a k\u00fd\u010deln\u00edm kloubu. N\u011bkter\u00e9 stavy, jako porucha klenby no\u017en\u00ed a ztuhlost hlezenn\u00e9ho kloubu, omezuj\u00ed\u00a0\u010dinnost \u017eiln\u011b-svalov\u00e9 pumpy a mus\u00ed b\u00fdt korigov\u00e1ny. Ne\u017e dojde k n\u00e1prav\u011b nebo nen\u00ed-li n\u00e1prava mo\u017en\u00e1, pak doporu\u010dujeme ru\u010dn\u00ed mas\u00e1\u017ee nohou, kter\u00e9 aktivuj\u00ed \u017eiln\u00ed n\u00e1vrat a stimuluj\u00ed cirkulaci. Lze je pou\u017e\u00edt i v prevenci hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy u le\u017e\u00edc\u00edch pacient\u016f.<\/p>\n<p>Nejjednodu\u0161\u0161\u00edm a nejfyziologi\u010dt\u011bj\u0161\u00edm cvi\u010den\u00edm je prost\u00e1 ch\u016fze. Je-li st\u00e1n\u00ed \u010di sezen\u00ed nevyhnuteln\u00e9 (cestov\u00e1n\u00ed), pak \u017eiln\u011b-svalovou pumpu aktivujeme cvi\u010den\u00edm. Vhodn\u00e9 je st\u0159\u00edd\u00e1n\u00ed plant\u00e1rn\u00ed flexe s dorz\u00e1ln\u00ed extenz\u00ed, opakovan\u00fd stoj na \u0161pi\u010dky, vle\u017ee pak procvi\u010den\u00ed jak velk\u00fdch kloub\u016f, tak prst\u016f nohou.<\/p>\n<p>Je nutno dodr\u017eovat n\u011bkter\u00e9 z\u00e1sady: zredukovat hmotnost, omezit sezen\u00ed \u010di strnul\u00e9 st\u00e1n\u00ed, zvolit vhodn\u00fd sport. Pacient\u016fm s \u017eiln\u00edm onemocn\u011bn\u00edm doporu\u010dujeme sporty jako plav\u00e1n\u00ed, cyklistika, b\u011bh a b\u011bh na ly\u017e\u00edch. Za m\u00e9n\u011b vhodn\u00e9 jsou pova\u017eov\u00e1ny aktivity, p\u0159i nich\u017e doch\u00e1z\u00ed ke zv\u00fd\u0161en\u00ed nitrob\u0159i\u0161n\u00edho tlaku (zved\u00e1n\u00ed t\u011b\u017ek\u00fdch b\u0159emen) nebo fixaci hlezenn\u00e9ho kloubu (sjezdov\u00e9 ly\u017eov\u00e1n\u00ed).<\/p>\n<p>Doporu\u010dujeme podlo\u017een\u00ed postele u nohou, co\u017e p\u0159\u00edzniv\u011b ovlivn\u00ed \u017eiln\u00ed n\u00e1vrat a m\u016f\u017ee p\u0159isp\u011bt k redukci otok\u016f p\u0159es noc. P\u0159\u00edzniv\u011b p\u016fsob\u00ed chladn\u00e9 koupele doln\u00edch kon\u010detin. Chlad vede jednak k vasokonstrikci, jednak tlum\u00ed z\u00e1n\u011btliv\u00fd proces. Pot\u00e9, co p\u0159estane p\u016fsobit, mus\u00edme po\u010d\u00edtat s reaktivn\u00ed hyperemi\u00ed. Naopak hork\u00e9 prost\u0159ed\u00ed m\u016f\u017ee pot\u00ed\u017ee zhor\u0161ovat. Tolerance sauny je individu\u00e1ln\u00ed. Sn\u00e1\u0161\u00ed-li ji pacient, pak mu ji nezakazujeme.<\/p>\n<p>Pacienta s chronickou \u017eiln\u00ed insuficienc\u00ed sezn\u00e1m\u00edme se z\u00e1kladn\u00edmi patofyziologick\u00fdmi principy onemocn\u011bn\u00ed a aktivn\u011b ho do l\u00e9\u010dby zapoj\u00edme. Jeho spolupr\u00e1ce je nutn\u00e1 zejm\u00e9na tehdy, nen\u00ed-li mo\u017en\u00e9 pot\u00ed\u017ee odstranit chirurgicky.<\/p>\n<h4>10.4.4 Kompresivn\u00ed terapie v prevenci a l\u00e9\u010db\u011b \u017eiln\u00edch onemocn\u011bn\u00ed doln\u00edch kon\u010detin<\/h4>\n<p>Kompresivn\u00ed terapie je \u00fa\u010dinnou metodou v l\u00e9\u010db\u011b onemocn\u011bn\u00ed \u017eiln\u00edho i lymfatick\u00e9ho syst\u00e9mu doln\u00edch kon\u010detin. Podporuje nebo nahrazuje nedostate\u010dnou \u017eiln\u011b-svalovou pumpu. Jej\u00edm c\u00edlem je zabr\u00e1nit \u017eiln\u00edmu m\u011bstn\u00e1n\u00ed a jeho n\u00e1sledk\u016fm. P\u0159i aplikaci zevn\u00ed komprese kles\u00e1 reflux v hlubok\u00e9m \u017eiln\u00edm syst\u00e9mu. Inkompetentn\u00ed chlopn\u011b se p\u0159ibl\u00ed\u017een\u00edm sv\u00fdch c\u00edp\u016f mohou st\u00e1t kompetentn\u00edmi. Komprese ur ychluje \u017eiln\u00ed tok, zvy\u0161uje fibrinolytickou aktivitu \u017eiln\u00ed st\u011bny a zmen\u0161uje riziko tromb\u00f3zy. Spr\u00e1vn\u011b aplikovan\u00e1 zevn\u00ed komprese m\u00e1 nejvy\u0161\u0161\u00ed tlak v oblasti hlezna, sm\u011brem proxim\u00e1ln\u00edm tlak kles\u00e1. Jedn\u00e1 se o tzv. <b>graduovanou kompresi.<\/b><\/p>\n<p>P\u0159i kompresivn\u00ed terapii rozli\u0161ujeme f\u00e1zi terapeutickou a udr\u017eovac\u00ed. Terapeutick\u00e1 trv\u00e1 tak dlouho, a\u017e ji\u017e nelze dos\u00e1hnout dal\u0161\u00ed redukce ed\u00e9mu, nebo do zhojen\u00ed v\u0159edu. V terapeutick\u00e9 f\u00e1zi jsou vhodn\u011bj\u0161\u00ed neelastick\u00e1 obinadla. Na terapeutickou f\u00e1zi navazuje f\u00e1ze udr\u017eovac\u00ed, jej\u00edm\u017e c\u00edlem je zachovat stav dosa\u017een\u00fd ve f\u00e1zi terapeutick\u00e9. Lze u\u017e\u00edt elastick\u00e9 materi\u00e1ly. Elastick\u00fd materi\u00e1l vykazuje men\u0161\u00ed efekt na hlubok\u00fd \u017eiln\u00ed syst\u00e9m a men\u0161\u00ed pracovn\u00ed tlak. Na noc jej sund\u00e1v\u00e1me. Naopak neelastick\u00fd materi\u00e1l m\u00e1 vy\u0161\u0161\u00ed pracovn\u00ed tlak a lep\u0161\u00ed efekt na hlubok\u00fd \u017eiln\u00ed syst\u00e9m. Z\u016fst\u00e1v\u00e1 p\u0159ilo\u017een del\u0161\u00ed dobu. V\u00fdznamn\u00e1 redukce pr\u016fm\u011bru VSM a hlubok\u00fdch femor\u00e1ln\u00edch \u017eil se projev\u00ed a\u017e p\u0159i tlaku od 40 mm Hg. Tlak 40\u201360 mm Hg na stehn\u011b lze doc\u00edlit spr\u00e1vn\u011b nalo\u017eenou kr\u00e1tkota\u017enou band\u00e1\u017e\u00ed. Stehenn\u00ed pun\u010dochy II. kompresivn\u00ed t\u0159\u00eddy vykazuj\u00ed tlak na stehn\u011b kolem 15\u201320 mm Hg, co\u017e nesta\u010d\u00ed k ovlivn\u011bn\u00ed hemodynamiky \u0161irok\u00fdch povrchov\u00fdch a hlubok\u00fdch \u017eil stehna.<\/p>\n<p>Kompresivn\u00ed terapie u pacient\u016f s oboustrann\u00fdmi otoky doln\u00edch kon\u010detiny vede k n\u00e1r\u016fstu centr\u00e1ln\u00edho objemu krve a\u017e o 20%. Hroz\u00ed tak p\u0159et\u00ed\u017een\u00ed srdce u predisponovan\u00fdch nemocn\u00fdch.<\/p>\n<h6>KOMPRESIVN\u00cd BAND\u00c1\u017d<\/h6>\n<p><strong>O \u00fa\u010dinnosti kompresivn\u00ed band\u00e1\u017ee rozhoduj\u00ed \u010dty\u0159i faktory:<\/strong><\/p>\n<ol>\n<li><strong>tlak<br \/>\n<\/strong>\u00da\u010dinn\u00e1 komprese mus\u00ed m\u00edt spr\u00e1vn\u00fd tlak, tj. p\u0159\u00edli\u0161\u00a0n\u00edzk\u00fd tlak m\u00e1 za n\u00e1sledek ne\u00fa\u010dinnost komprese\u00a0a kon\u010detinu sp\u00ed\u0161e jen zah\u0159\u00edv\u00e1, co\u017e nen\u00ed pro pacienty s \u017eiln\u00edm onemocn\u011bn\u00edm optim\u00e1ln\u00ed. Naopak p\u0159\u00edli\u0161\u00a0vysok\u00fd tlak m\u016f\u017ee zp\u016fsobit \u0161kody sv\u00e9mu nositeli\u00a0a b\u00fdv\u00e1 \u0161patn\u011b tolerov\u00e1n.<\/li>\n<li><strong>vrstvy<br \/>\n<\/strong>Ka\u017ed\u00e1 band\u00e1\u017e je p\u0159ikl\u00e1d\u00e1na tak, aby se jednotliv\u00e9\u00a0vrstvy p\u0159ekr\u00fdvaly, proto vlastn\u011b neexistuje jednovrstevn\u00e1 band\u00e1\u017e. Dvouvrstevn\u00e1 band\u00e1\u017e je charakterizov\u00e1na 50% p\u0159ekryt\u00edm, v\u00edcevrstevn\u00e1 band\u00e1\u017e m\u00e1\u00a0p\u0159ekryt\u00ed v\u011bt\u0161\u00ed nebo je slo\u017eena z v\u00edce vrstev. V\u00edcevrstevn\u00e1 band\u00e1\u017e je tvo\u0159ena v\u00edce ne\u017e dv\u011bma vrstvami\u00a0stejn\u00e9ho materi\u00e1lu nebo v\u00edce vrstvami r\u016fzn\u00fdch\u00a0materi\u00e1l\u016f.<\/li>\n<li><strong>komponenty<br \/>\n<\/strong>Komponentami rozum\u00edme r\u016fzn\u00e9 materi\u00e1ly u\u017eit\u00e9\u00a0ke kompresivn\u00ed band\u00e1\u017ei. Tyto materi\u00e1ly mohou m\u00edt\u00a0r\u016fznou funkci (ochrana, retence, podlo\u017een\u00ed). Kombinace r\u016fzn\u00fdch materi\u00e1l\u016f ovliv\u0148uje tlak a tuhost\u00a0band\u00e1\u017ee.<\/li>\n<li><strong>elasticita<br \/>\n<\/strong>Materi\u00e1ly mohou b\u00fdt elastick\u00e9 (dlouhota\u017en\u00e9) a neelastick\u00e9 (kr\u00e1tkota\u017en\u00e9). Elasticita je definov\u00e1na\u00a0jako procento prodlou\u017een\u00ed band\u00e1\u017ee s\u00edly 10 N\/cm \u0161\u00ed\u0159ky. Kompresivn\u00ed terapie m\u016f\u017ee b\u00fdt realizov\u00e1na kompresivn\u00ed band\u00e1\u017e\u00ed, kompresivn\u00ed pun\u010dochou (KP) nebo intermitentn\u00ed pneumatickou kompres\u00ed.Kompresivn\u00ed band\u00e1\u017e b\u00e9rce sah\u00e1 od prst\u016f a\u017e pod koleno, kompresivn\u00ed band\u00e1\u017e stehna a\u017e do proxim\u00e1ln\u00ed \u010d\u00e1sti stehna. V\u017edy zakr\u00fdv\u00e1 i patu, jinak je nebezpe\u010d\u00ed vzniku otoku kolem kotn\u00edk\u016f. Obvaz p\u0159ikl\u00e1d\u00e1me p\u0159i dorz\u00e1ln\u00ed flexi v hlezenn\u00edm kloubu. Nesm\u00ed zp\u016fsobovat otlaky, z\u00e1\u0159ezy ani p\u016fsobit bolest. P\u0159i nakl\u00e1d\u00e1n\u00ed obvazu respektujeme Laplace\u016fv z\u00e1kon, ze kter\u00e9ho vypl\u00fdv\u00e1, \u017ee p\u0159i stejn\u00e9m nap\u011bt\u00ed obvazu je tlak v\u011bt\u0161\u00ed nad \u010d\u00e1stmi kon\u010detiny s men\u0161\u00edm polom\u011brem (hrana tibie) a men\u0161\u00ed u rovn\u00fdch ploch.Kompresivn\u00ed band\u00e1\u017ee jsou vhodn\u00e9 zejm\u00e9na v l\u00e9\u010db\u011b \u017eiln\u00edch ulcerac\u00ed, akutn\u00ed hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy (H\u017dT) a lymfed\u00e9mu, redukuj\u00ed krv\u00e1cen\u00ed po operaci varix\u016f. Jejich nev\u00fdhodou je ztr\u00e1ta tlaku, tak\u017ee je nutn\u00e9 je b\u011bhem dne znovu nakl\u00e1dat. Rozli\u0161ujeme obinadla kr\u00e1tkota\u017en\u00e1 (s prota\u017eitelnost\u00ed do 70%), st\u0159edn\u011bta\u017en\u00e1 (s prota\u017eitelnost\u00ed do 140%) a dlouhota\u017en\u00e1 (s prota\u017eitelnost\u00ed nad 140%).Obvazy mohou b\u00fdt do\u010dasn\u00e9 nebo trval\u00e9. Do\u010dasn\u00e9 si p\u0159ikl\u00e1daj\u00ed pacienti sami, nejl\u00e9pe, stejn\u011b jako KP, je\u0161t\u011b na l\u016f\u017eku r\u00e1no a sn\u00edmaj\u00ed je ve\u010der, op\u011bt na l\u016f\u017eku. V\u011bt\u0161inou se jedn\u00e1 o st\u0159edn\u011bnebo dlouhota\u017en\u00e1 obinadla. Jsou indikov\u00e1na zejm\u00e9na tam, kde je t\u0159eba \u010dast\u011bj\u0161\u00edch p\u0159evaz\u016f, jako nap\u0159\u00edklad u b\u00e9rcov\u00fdch ulcerac\u00ed, a tam, kde nen\u00ed dostupn\u00fd \u0161kolen\u00fd person\u00e1l. Pou\u017e\u00edvaj\u00ed se obinadla \u0161\u00ed\u0159e\u00a08\u201312 cm, pro band\u00e1\u017e b\u00e9rce jsou pot\u0159eba v\u011bt\u0161inou dv\u011b. V oblasti hlezna pou\u017eijeme sp\u00ed\u0161e u\u017e\u0161\u00ed, aby nebr\u00e1nila pohybu v kloubu. P\u0159\u00edli\u0161 \u00fazk\u00e1 obinadla se za\u0159ez\u00e1vaj\u00ed. Obvaz za\u010d\u00edn\u00e1me nakl\u00e1dat na n\u00e1rtu, jde i p\u0159es patu sm\u011brem proxim\u00e1ln\u00edm. Mus\u00ed b\u00fdt pod st\u00e1l\u00fdm tahem, co\u017e podporujeme siln\u011bj\u0161\u00edm popota\u017een\u00edm na later\u00e1ln\u00ed a medi\u00e1ln\u00ed stran\u011b, tj. dvakr\u00e1t b\u011bhem jedn\u00e9 ot\u00e1\u010dky. Trval\u00e9 obvazy z\u016fst\u00e1vaj\u00ed i p\u0159i sp\u00e1nku a b\u00fdvaj\u00ed p\u0159ilo\u017eeny n\u011bkolik dn\u016f a\u017e t\u00fddn\u016f. Pou\u017e\u00edvaj\u00ed se kr\u00e1tkota\u017en\u00e1 obinadla. Jejich nev\u00fdhodou je to, \u017ee je mus\u00ed v\u017edy p\u0159ikl\u00e1dat \u0161kolen\u00fd pracovn\u00edk a h\u016f\u0159e se zaji\u0161\u0165uje hygiena pod obvazem.<\/li>\n<\/ol>\n<h6>INTERMITENTN\u00cd PNEUMATICK\u00c1 KOMPRESE<\/h6>\n<p>Intermitentn\u00ed pneumatick\u00e1 komprese je vhodn\u00e1 v prevenci poopera\u010dn\u00ed tromb\u00f3zy, v l\u00e9\u010db\u011b posttrombotick\u00e9ho syndromu a lymfed\u00e9mu. Spo\u010d\u00edv\u00e1 v rytmick\u00e9 zevn\u00ed kompresi doln\u00ed kon\u010detiny, ide\u00e1ln\u011b ka\u017edou\u00a010. minutu, tlakem kolem 40 mm Hg. Zrychluje krevn\u00ed tok v \u017eiln\u00edm syst\u00e9mu a zabra\u0148uje st\u00e1ze.<\/p>\n<h6>KOMPRESIVN\u00cd PUN\u010cOCHY<\/h6>\n<p>Kompresivn\u00ed pun\u010dochy jsou z\u00e1kladn\u00edm terapeutick\u00fdm prvkem v l\u00e9\u010db\u011b onemocn\u011bn\u00ed \u017eiln\u00edho a lymfatick\u00e9ho syst\u00e9mu. Jsou vyr\u00e1b\u011bny ze z\u00e1ta\u017en\u00e9 v\u00fdpl\u0148kov\u00e9 pleteniny na ploch\u00fdch (se \u0161vem) nebo okrouhl\u00fdch (beze\u0161v\u00e9) pletac\u00edch stroj\u00edch. Z\u00e1klad pru\u017en\u00e9ho vl\u00e1kna tvo\u0159\u00ed lastodien nebo elastin. Pro kompresi m\u00e1 v\u00fdznam v\u00fdpl\u0148kov\u00e1 nit tvo\u0159en\u00e1 zpravidla op\u0159eden\u00fdm pru\u017en\u00fdm j\u00e1drem a jako op\u0159ed se pou\u017e\u00edv\u00e1 p\u0159\u00edze (up\u0159eden\u00e1 nit z p\u0159\u00edrodn\u00edch nebo syntetick\u00fdch vl\u00e1ken o ur\u010dit\u00e9 d\u00e9lce \u2013 staplu) nebo hedv\u00e1b\u00ed (nekone\u010dn\u00e9 vl\u00e1kno p\u0159\u00edrodn\u00ed nebo syntetick\u00e9). Z\u00e1kladn\u00ed nit se skl\u00e1d\u00e1 ze svazku vl\u00e1ken (fibril). Jemnost nit\u011b se ud\u00e1v\u00e1 v dtex (tex \u2013 v\u00e1ha 1 km p\u0159\u00edze v gramech, dtex = decitex). Pokud je mno\u017estv\u00ed fibril v\u011bt\u0161\u00ed ne\u017e \u010d\u00edslo jemnosti udan\u00e9 v dtex, \u0159\u00edk\u00e1me o materi\u00e1lu, \u017ee je to mikrovl\u00e1kno. Z p\u0159\u00edrodn\u00edch vl\u00e1ken se nej\u010dast\u011bji pou\u017e\u00edv\u00e1 bavlna a ze syntetick\u00fdch polyamid. Pro zlep\u0161en\u00ed mechanick\u00fdch vlastnost\u00ed se pou\u017e\u00edv\u00e1 kade\u0159en\u00fd polyamid (teplem nebo prota\u017een\u00edm p\u0159es ostrou hranu).<\/p>\n<p>Kompresivn\u00ed pun\u010dochy mus\u00ed odpov\u00eddat norm\u011b (t. \u010d. se vyu\u017e\u00edv\u00e1 n\u011bmeck\u00e1 norma RAL). Maj\u00ed r\u016fzn\u00e9 d\u00e9lky (l\u00fdtkov\u00e1, stehenn\u00ed, kalhotov\u00e9 pun\u010dochy). Mohou b\u00fdt s otev\u0159enou \u010di zav\u0159enou \u0161pic\u00ed, oblast \u0161pice by m\u011bla b\u00fdt elastick\u00e1, aby se zabr\u00e1nilo konstrikci. V nenata\u017een\u00e9m stavu maj\u00ed tlou\u0161\u0165ku 0,5\u20131,4 mm a obsahuj\u00ed polyamid, elastan, bavlnu, elastodien, visk\u00f3zu a mikrovl\u00e1kna.<\/p>\n<p>Pun\u010dochy s n\u00edzk\u00fdm tlakem (10\u201315 mm Hg) maj\u00ed v\u00fdznam pro redukci otoku po del\u0161\u00edm sezen\u00ed nebo st\u00e1n\u00ed a zrychluj\u00ed tok krve u le\u017e\u00edc\u00edch. Zm\u00edr\u0148uj\u00ed p\u0159\u00edznaky \u017eiln\u00edho onemocn\u011bn\u00ed, jako pocit t\u011b\u017ek\u00fdch doln\u00edch kon\u010detin u pacient\u016f s leh\u010d\u00edm posti\u017een\u00edm \u017eiln\u00edho syst\u00e9mu a v gravidit\u011b. Mohou b\u00fdt tak\u00e9 pou\u017eity k fixaci kryt\u00ed nalo\u017een\u00e9ho na b\u00e9rcovou ulceraci. Maj\u00ed v\u00fdznam v prevenci TEN u le\u017e\u00edc\u00edch pacient\u016f, zvl\u00e1\u0161t\u011b po operaci.<\/p>\n<p>Pun\u010dochy s vy\u0161\u0161\u00edmi tlaky (20\u201330 mm Hg) jsou indikov\u00e1ny pro vzp\u0159\u00edmenou polohu. U pacient\u016f s chronickou \u017eiln\u00ed insuficienc\u00ed sni\u017euj\u00ed reflux a podporuj\u00ed \u017eiln\u011b-svalovou pumpu. Jsou indikov\u00e1ny po sklerotizaci varix\u016f, v t\u011bhotenstv\u00ed, pro l\u00e9\u010dbu akutn\u00ed H\u017dT. Vysok\u00e9 tlaky (30\u201340 mmHg) jsou vhodn\u00e9 pro redukci lipodermatoskler\u00f3zy, pro l\u00e9\u010dbu lymfed\u00e9mu a prevenci recidivy b\u00e9rcov\u00fdch ulcerac\u00ed \u017eiln\u00ed etiologie a sni\u017euj\u00ed v\u00fdskyt posttrombotick\u00e9ho syndromu.<\/p>\n<p>Vysok\u00e9 tlaky mohou v\u00e9st k po\u0161kozen\u00ed k\u016f\u017ee. St\u00e1l\u00fd tlak vy\u0161\u0161\u00ed ne\u017e 70 mm Hg, zejm\u00e9na nad kostn\u00edmi prominencemi, je pova\u017eov\u00e1n za horn\u00ed hranici. P\u0159i pou\u017eit\u00ed intermitentn\u00ed pneumatick\u00e9 komprese lze u\u017e\u00edt i tlaky vy\u0161\u0161\u00ed ne\u017e 120 mm Hg. Z\u00e1sadn\u00ed v\u00fdznam p\u0159i p\u0159edpisu kompresivn\u00ed pun\u010dochy m\u00e1 p\u0159esn\u00e9 zm\u011b\u0159en\u00ed m\u011br definovan\u00fdch m\u00edst, tj. obvod nad kotn\u00edkem a dal\u0161\u00edmi m\u00edsty doln\u00ed kon\u010detiny. V p\u0159\u00edpad\u011b, \u017ee se m\u00edry u pacienta vymykaj\u00ed b\u011b\u017en\u00fdm rozm\u011br\u016fm, ka\u017ed\u00fd v\u00fdrobce zhotov\u00ed pun\u010dochu na m\u00edru. V akutn\u00ed f\u00e1zi je vhodn\u00fd kompresivn\u00ed obvaz (Kaletov\u00e1, 2006). Po stabilizaci stavu (\u00fastup otoku, zhojen\u00ed ulcerace) lze p\u0159edepsat KP. V pokro\u010dil\u00fdch stadi\u00edch chronick\u00e9 ven\u00f3zn\u00ed insuficience b\u00fdv\u00e1 posti\u017eena i k\u016f\u017ee, kter\u00e1 m\u016f\u017ee b\u00fdt citliv\u00e1 na r\u016fzn\u00e9 materi\u00e1ly. U takov\u00fdch pacient\u016f lze volit pun\u010dochy v antimikrobi\u00e1ln\u00ed \u00faprav\u011b.<\/p>\n<p>Kontraindikace KP: pokro\u010dil\u00e1 stadia ischemick\u00e9 choroby doln\u00edch kon\u010detin, kritick\u00e1 kon\u010detinov\u00e1 ischemie, dekompenzovan\u00e1 kardi\u00e1ln\u00ed insuficience, dermat\u00f3zy s v\u00fdraznou exsudac\u00ed, intolerance n\u011bkter\u00e9 komponenty pun\u010dochy. Nevhodn\u011b zvolen\u00e1 KP m\u016f\u017ee b\u00fdt ne\u00fa\u010dinn\u00e1 nebo m\u016f\u017ee zp\u016fsobit tlakov\u00e9 po\u0161kozen\u00ed k\u016f\u017ee a perifern\u00edch nerv\u016f.<\/p>\n<p>V\u011bt\u0161inou je \u010dast\u011bji p\u0159edepisov\u00e1na l\u00fdtkov\u00e1 kompresivn\u00ed pun\u010docha. Na l\u00fdtku se manifestuj\u00ed zn\u00e1mky chronick\u00e9 \u017eiln\u00ed insuficience (CVI) a lok\u00e1ln\u00ed komprese zlep\u0161uje mirkocirkulaci v nejv\u00edce posti\u017een\u00e9 oblasti. M\u011b\u0159en\u00ed uk\u00e1zala, \u017ee stehenn\u00ed KP nezv\u00fd\u0161\u00ed mno\u017estv\u00ed vypuzen\u00e9 krve ve srovn\u00e1n\u00ed s l\u00fdtkovou KP (Partsch,<br \/>\n1984). Stehenn\u00ed pun\u010docha m\u016f\u017ee sv\u00e9mu nositeli zp\u016fsobovat ur\u010dit\u00fd diskomfort v oblasti fossa poplitea p\u0159i sezen\u00ed.<\/p>\n<p>Je-li indikov\u00e1na komprese &gt; 40 mm Hg, je vhodn\u011bj\u0161\u00ed pou\u017e\u00edt kr\u00e1tkota\u017en\u00e9 neelastick\u00e9 materi\u00e1ly ne\u017e KP. KP o hodnot\u00e1ch tlaku 40 mm Hg se \u0161patn\u011b aplikuj\u00ed a nejsou dob\u0159e tolerov\u00e1ny. Neelastick\u00e1 band\u00e1\u017e m\u00e1 lep\u0161\u00ed hemodynamick\u00fd efekt ne\u017e elastick\u00e1. Je to zp\u016fsobeno vy\u0161\u0161\u00edm pracovn\u00edm tlakem. Tlak band\u00e1\u017ee a technika jej\u00edho nalo\u017een\u00ed jsou v\u00fdrazn\u011b z\u00e1visl\u00e9 na osob\u011b, kter\u00e1 band\u00e1\u017e p\u0159ikl\u00e1d\u00e1.<\/p>\n<h6>INDIKACE KOMPRESIVN\u00cd TERAPIE<\/h6>\n<ul>\n<li><strong>Kompresivn\u00ed terapie u pacient\u016f s hlubokou \u017eiln\u00ed tromb\u00f3zou<br \/>\n<\/strong>V terapii akutn\u00ed hlubok\u00e9 \u017eiln\u00ed tromb\u00f3zy je tradi\u010dn\u00ed klid na l\u016f\u017eku nahrazen kompresivn\u00ed terapi\u00ed s ch\u016fz\u00ed. Tato l\u00e9\u010dba nezvy\u0161uje riziko PE, vykazuje rychlej\u0161\u00ed \u00fastup bolesti a otoku a je i lep\u0161\u00ed kvalita \u017eivota. Komprese s pohybem redukuje \u0161\u00ed\u0159en\u00ed trombu a m\u00e1 v\u00fdznam v prevenci posttrombotick\u00e9ho syndromu. Tuto l\u00e9\u010dbu lze prov\u00e1d\u011bt ambulantn\u011b. Samoz\u0159ejmost\u00ed je antikoagula\u010dn\u00ed l\u00e9\u010dba (LWMH, warfarin). \u00da\u010dinn\u00e1 konzervativn\u00ed l\u00e9\u010dba (antikoagula\u010dn\u00ed, kompresivn\u00ed) v prvn\u00edch 24 hodin\u00e1ch po diagn\u00f3ze H\u017dT m\u00e1 z\u00e1sadn\u00ed v\u00fdznam pro sn\u00ed\u017een\u00ed pravd\u011bpodobnosti recidivy. Klid na l\u016f\u017eku v prvn\u00edch 24 hodin\u00e1ch podporuje propagaci trombu \u2013 viz Virchowova tria. U n\u011bkter\u00fdch diagn\u00f3z m\u016f\u017ee b\u00fdt klid na l\u016f\u017eku dokonce \u0161kodliv\u00fd.Nez\u00e1visle na lokalizaci trombu zahajujeme antikoagula\u010dn\u00ed l\u00e9\u010dbu (LMWH, warfarin), indikujeme\u00a0pohyb a kompresi. Vhodn\u00e1 je pevn\u00e1, neelastick\u00e1 band\u00e1\u017e nebo KP II.\u2013III. t\u0159\u00eddy. M\u011bla by b\u00fdt ponech\u00e1na alespo\u0148 jeden rok.<\/li>\n<li><strong>Kompresivn\u00ed terapie v prevenci posttrombotick\u00e9ho syndromu<br \/>\n<\/strong>Definice posttrombotick\u00e9ho syndromu nen\u00ed jednotn\u00e1 (krit\u00e9ria pro dg. posttrombotick\u00e9ho syndromu: flebotromb\u00f3za v anamn\u00e9ze, klinick\u00e9 zn\u00e1mky a symptomy a objektivn\u00ed potvrzen\u00ed chlopenn\u00ed dysfunkce \u2013 DUS, pletyzmograficky), v\u0161eobecn\u011b j\u00edm rozum\u00edme p\u0159\u00edtomnost trofick\u00fdch ko\u017en\u00edch zm\u011bn (C4 a v\u00edce dle CEAP klasifikace) spolu se subjektivn\u00edmi obt\u00ed\u017eemi nemocn\u00e9ho (bolest, pocit t\u011b\u017ek\u00fdch nohou, pocit horka, nap\u011bt\u00ed, \u00fanavnost) po prod\u011blan\u00e9 hlubok\u00e9 \u017eiln\u00ed tromb\u00f3ze. Prolongovan\u00e9 (d\u00e9le ne\u017e\u00a06 m\u011bs\u00edc\u016f trvaj\u00edc\u00ed) no\u0161en\u00ed kompresivn\u00edch pun\u010doch po hlubok\u00e9 \u017eiln\u00ed tromb\u00f3ze signifikantn\u011b redukuje p\u0159\u00edznaky a m\u016f\u017ee p\u0159edch\u00e1zet rozvoji posttrombotick\u00fdch ko\u017en\u00edch zm\u011bn.<\/li>\n<li><strong>Kompresivn\u00ed terapie u pacient\u016f s tromboflebitidou<br \/>\n<\/strong>Nez\u00e1visle na tom, zda je posti\u017eena varik\u00f3zn\u011b zm\u011bn\u011bn\u00e1 v\u00e9na \u010di zdrav\u00e1 v\u00e9na, p\u0159eva\u017euje-li slo\u017eka z\u00e1n\u011btliv\u00e1 \u010di trombogenn\u00ed a je-li proces omezen pouze na samotnou v\u00e9nu nebo i na jej\u00ed okol\u00ed (periphlebitis), je z\u00e1kladn\u00edm terapeutick\u00fdm principem komprese a mobilizace. Komprese m\u00e1 za n\u00e1sledek regresi z\u00e1n\u011btliv\u00e9ho procesu, \u00fastup bolesti a redukci otoku. Vhodn\u00e1 je KP II. t\u0159\u00eddy nebo band\u00e1\u017e.<\/li>\n<li><strong>Kompresivn\u00ed terapie v leteck\u00e9 doprav\u011b<br \/>\n<\/strong>Vztah mezi dlouh\u00fdm sezen\u00edm a plicn\u00ed emboli\u00ed (PE)\u00a0je zn\u00e1m ji\u017e z dob druh\u00e9 sv\u011btov\u00e9 v\u00e1lky, kdy nucen\u00e9\u00a0dlouhodob\u00e9 sezen\u00ed v protileteck\u00fdch krytech m\u011blo\u00a0za n\u00e1sledek fat\u00e1ln\u00ed PE. Stejn\u011b tak se jev\u00ed spojitost\u00a0mezi dlouh\u00fdmi lety a vznikem H\u017dT. U pacient\u016f,\u00a0kte\u0159\u00ed nemaj\u00ed rizikov\u00e9 faktory pro H\u017dT, je jej\u00ed incidence kolem 1,6%, u pacient\u016f s rizikov\u00fdmi faktory\u00a0dosahuje a\u017e 5%. Za rizikov\u00e9 faktory se pova\u017euje\u00a0anamn\u00e9za H\u017dT, vy\u0161\u0161\u00ed v\u011bk, trauma v ned\u00e1vn\u00e9 minulosti, varixy doln\u00edch kon\u010detin, obezita, srde\u010dn\u00ed\u00a0onemocn\u011bn\u00ed, malign\u00ed onemocn\u011bn\u00ed, hormon\u00e1ln\u00ed terapie, omezen\u00ed hybnosti pro posti\u017een\u00ed kost\u00ed nebo\u00a0kloub\u016f, t\u011bhotenstv\u00ed.<br \/>\nV prevenci m\u00e1 v\u00fdznam kompresivn\u00ed pun\u010docha\u00a0s tlakem u kotn\u00edku (obvod \u201eb\u201c) 14\u201330 mm Hg, kter\u00e1 sou\u010dasn\u011b redukuje otok kon\u010detiny. Snad by mohlo b\u00fdt ni\u017e\u0161\u00ed riziko vzniku H\u017dT u pacient\u016f sed\u00edc\u00edch\u00a0v uli\u010dce ne\u017e u pacient\u016f u okna nebo na st\u0159edn\u00edm<br \/>\nsedadle, pravd\u011bpodobn\u011b pro snaz\u0161\u00ed mo\u017enost pohybu. Zat\u00edmco p\u0159\u00ednos kompresivn\u00ed pun\u010dochy a aplikace LMWH lze pova\u017eovat za prok\u00e1zan\u00fd, ostatn\u00ed\u00a0preventivn\u00ed opat\u0159en\u00ed sp\u00ed\u0161e p\u0159edpokl\u00e1d\u00e1me \u2013 dostatek tekutin, minimum alkoholu a k\u00e1vy, pravideln\u00e9\u00a0prota\u017een\u00ed doln\u00edch kon\u010detin, st\u0159\u00edd\u00e1n\u00ed plant\u00e1rn\u00ed\/dorz\u00e1ln\u00ed flexe v hlezenn\u00edm kloubu, kr\u00e1tk\u00e1 ch\u016fze ka\u017edou hodinu. Riziko vzniku PE je vy\u0161\u0161\u00ed u let\u016f del\u0161\u00edch ne\u017e 5000 km nebo trvaj\u00edc\u00edch d\u00e9le ne\u017e 5 hodin. Incidence PE se v t\u011bchto p\u0159\u00edpadech ud\u00e1v\u00e1 1,5 a\u017e 2,57 na milion cestuj\u00edc\u00edch. V medikament\u00f3zn\u00ed prevenci m\u00e1 v\u00fdznam LMWH, anopyrin nikoliv.<\/li>\n<li><strong>Kompresivn\u00ed terapie v t\u011bhotenstv\u00ed a \u0161estined\u011bl\u00ed<br \/>\n<\/strong>V t\u011bhotenstv\u00ed se riziko vzniku tromboembolick\u00e9 nemoci, ve srovn\u00e1n\u00ed s net\u011bhotn\u00fdmi \u017eenami, zvy\u0161uje t\u0159ia\u017e \u0161estkr\u00e1t, v \u0161estined\u011bl\u00ed dokonce \u010dtrn\u00e1ctkr\u00e1t. Riziko vzniku tromb\u00f3zy je nejvy\u0161\u0161\u00ed ve t\u0159et\u00edm trimestru a po porodu. Kompresivn\u00ed pun\u010dochy redukuj\u00ed symptomatologii \u017eiln\u00ed insuficience a sni\u017euj\u00ed reflux v safenofemor\u00e1ln\u00ed junkci. Vhodn\u00e9 jsou KP I. nebo II. t\u0159\u00eddy.<\/li>\n<li><strong>Kompresivn\u00ed terapie po operaci varix\u016f<\/strong>Aplikace kompresivn\u00ed band\u00e1\u017ee po operaci varix\u016f\u00a0je standardn\u00edm \u00fakonem. Sni\u017euje v\u00fdskyt tromboflebitidy, H\u017dT, zlep\u0161uje hojen\u00ed ran, redukuje bolest\u00a0a vznik hematomu. Nen\u00ed jednotn\u00fd n\u00e1zor na to, jak\u00a0dlouho po operaci zachovat kompresi, pravd\u011bpodobn\u011b sta\u010d\u00ed t\u00fdden, z\u00e1vis\u00ed ale na stadiu choroby\u00a0a rozsahu operace.<\/li>\n<li><strong>Kompresivn\u00ed terapie u aktivn\u00ed b\u00e9rcov\u00e9 ulcerace (C6)<br \/>\n<\/strong>Kompresivn\u00ed terapie je pova\u017eov\u00e1na za z\u00e1kladn\u00ed stavebn\u00ed k\u00e1men p\u0159i l\u00e9\u010db\u011b b\u00e9rcov\u00e9 ulcerace. Z\u00e1sadn\u00ed\u00a0v\u00fdznam zde m\u00e1 neelastick\u00e9 obinadlo s vysok\u00fdm\u00a0pracovn\u00edm a n\u00edzk\u00fdm klidov\u00fdm tlakem. Pro vyrovn\u00e1n\u00ed nerovnost\u00ed nebo pro zv\u00fd\u0161en\u00ed lok\u00e1ln\u00edho tlaku\u00a0lze pou\u017e\u00edt pod band\u00e1\u017e houbi\u010dku. <strong>B\u00e9rcovou ulceraci \u017eiln\u00ed etiologie<\/strong> je mo\u017en\u00e9 zhojit pouhou band\u00e1\u017e\u00ed. V l\u00e9\u010db\u011b b\u00e9rcov\u00e9 ulcerace lze pou\u017e\u00edt i kompresivn\u00ed pun\u010dochu, p\u0159esto\u017ee je elastick\u00e1. Bu\u010f b\u011b\u017enou,kter\u00e1 se obt\u00ed\u017en\u011b nakl\u00e1d\u00e1 a h\u016f\u0159e se udr\u017euje jej\u00ed \u010distota p\u0159i floridn\u00ed ulceraci, nebo speci\u00e1ln\u00ed pun\u010dochy\u00a0pro l\u00e9\u010dbu ulcerac\u00ed se zipem. Nov\u011bji se aplikuje zevn\u00ed\u00a0komprese v podob\u011b v\u00edce p\u00e1s\u016f (Deona fast \u2013 obr.\u00a012).<\/li>\n<li><em><em><strong>Kompresivn\u00ed terapie u zhojen\u00e9 b\u00e9rcov\u00e9 ulcerace (C5)<br \/>\n<\/strong><\/em><\/em><\/p>\n<p style=\"display: inline !important;\">U zhojen\u00e9 b\u00e9rcov\u00e9 ulcerace m\u00e1 kompresivn\u00ed terapie v\u00fdznam pro zachov\u00e1n\u00ed dosa\u017een\u00e9ho stavu, a to<\/p>\n<p style=\"display: inline !important;\">zejm\u00e9na tam, kde ji\u017e nen\u00ed mo\u017en\u00e1 l\u00e9\u010dba chirurgick\u00e1.<\/p>\n<p style=\"display: inline !important;\">Doporu\u010duje se KP III. t\u0159\u00eddy.<\/p>\n<\/li>\n<li><strong>Kompresivn\u00ed terapie u ko\u017en\u00edch zm\u011bn (ekz\u00e9m, pigmentace) \u017eiln\u00ed etiologie (C4a)<br \/>\n<\/strong>Kompresivn\u00ed terapie u ko\u017en\u00edch zm\u011bn typu ekz\u00e9m\u00a0a pigmentace, tj. ve stadiu C4a, nen\u00ed tak v\u00fdznamn\u00e1,\u00a0jako u jin\u00fdch onemocn\u011bn\u00ed \u017eiln\u00ed etiologie. Jeliko\u017e ale\u00a0tyto zm\u011bny vznikaj\u00ed n\u00e1sledkem \u017eiln\u00ed hypertenze,\u00a0i zde je komprese indikov\u00e1na. Dosta\u010duj\u00edc\u00ed je KP II.\u00a0t\u0159\u00eddy.<\/li>\n<li><strong>Kompresivn\u00ed terapie u ko\u017en\u00edch zm\u011bn (lipodermatoskler\u00f3za, atrophie blance) \u017eiln\u00ed etiologie (C4b)<br \/>\n<\/strong>Kompresivn\u00ed terapie je indikov\u00e1na u lipodermatoskler\u00f3zy a atrophie blanche, nebo\u0165 v\u00fdrazn\u011b redukuje tyto ko\u017en\u00ed zm\u011bny. Doporu\u010den\u00e9 jsou KP III. t\u0159\u00eddy.<\/li>\n<li><strong>Kompresivn\u00ed terapie u \u017eiln\u00edho otoku (C3)<br \/>\n<\/strong>Otoky \u017eiln\u00ed etiologie jsou z\u00e1kladn\u00ed a nej\u010dast\u011bj\u0161\u00ed indikac\u00ed kompresivn\u00ed terapie. Otok zhor\u0161uje cirkulaci\u00a0v k\u016f\u017ei, z\u00e1sobov\u00e1n\u00ed kysl\u00edkem a \u017eivinami. Pacienti\u00a0s otoky ud\u00e1vaj\u00ed pocit t\u011b\u017ek\u00fdch kon\u010detin, tenzi a bolesti. Kompresivn\u00ed terapie zlep\u0161\u00ed \u017eiln\u00ed hemodynamiku, tj. redukuje \u017eiln\u00ed reflux a \u017eiln\u00ed hypertenzi.\u00a0Vhodn\u00e9 jsou KP II. t\u0159\u00eddy.<\/li>\n<li><strong>Kompresivn\u00ed terapie u velk\u00fdch symptomatick\u00fdch varix\u016f C2S<br \/>\n<\/strong><\/p>\n<p style=\"display: inline !important;\">U symptomatick\u00fdch pacient\u016f (pocit t\u011b\u017ek\u00fdch nohou, bolesti, sv\u011bd\u011bn\u00ed) b\u00fdv\u00e1 kompresivn\u00ed terapie\u00a0\u00fa\u010dinn\u00e1, z\u00e1le\u017e\u00ed na pacientovi, je-li<\/p>\n<p style=\"display: inline !important;\">ochoten ji tolerovat.<\/p>\n<\/li>\n<li><em><em><strong>Kompresivn\u00ed terapie u velk\u00fdch asymptomatick\u00fdch varix\u016f C2A<br \/>\n<\/strong>U pacient\u016f s velk\u00fdmi varixy b\u00fdv\u00e1 kompresivn\u00ed terapie \u010dasto doporu\u010dov\u00e1na s c\u00edlem prevence progrese\u00a0choroby a komplikac\u00ed. Takov\u00fdto efekt kompresivn\u00ed\u00a0terapie v\u0161ak nebyl prok\u00e1z\u00e1n.<\/em><\/em><\/p>\n<p style=\"display: inline !important;\">Kompresivn\u00ed terapie je indikov\u00e1na i po sklerotizaci, jej\u00ed\u017e je ned\u00edlnou sou\u010d\u00e1st\u00ed, proto kompresivn\u00ed skleroterapie a po endoven\u00f3zn\u00edch laserov\u00fdch nebo RF operac\u00edch.<\/p>\n<\/li>\n<li><strong>Kompresivn\u00ed terapie u lymfatick\u00fdch otok\u016f<br \/>\n<\/strong><\/p>\n<div id=\"attachment_3275\" style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_363.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-3275\" class=\" wp-image-3275 \" title=\"Obr. 12 Zevn\u00ed komprese formou v\u00edce p\u00e1s\u016f\" alt=\"Obr. 12 Zevn\u00ed komprese formou v\u00edce p\u00e1s\u016f\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_363.jpg\" width=\"200\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_363.jpg 306w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_363-225x300.jpg 225w\" sizes=\"(max-width: 306px) 100vw, 306px\" \/><\/a><p id=\"caption-attachment-3275\" class=\"wp-caption-text\">Obr. 12 Zevn\u00ed komprese formou v\u00edce p\u00e1s\u016f<\/p><\/div>\n<p>P\u0159i terapii lymfed\u00e9mu jsou v po\u010d\u00e1tku indikov\u00e1na\u00a0neelastick\u00e1, kr\u00e1tkota\u017en\u00e1 obinadla. Jejich \u00fa\u010dinek je,\u00a0zejm\u00e9na p\u0159i v\u00edcevrstevn\u00e9m pou\u017eit\u00ed, v\u00fdrazn\u011bj\u0161\u00ed ne\u017e\u00a0p\u0159i aplikaci kompresivn\u00edch elastick\u00fdch pun\u010doch.I kdy\u017e nen\u00ed stanovena p\u0159esn\u00e1 hodnota tlaku, kter\u00fd\u00a0by m\u011bl b\u00fdt u lymfed\u00e9mu aplikov\u00e1n, obecn\u011b se doporu\u010duj\u00ed tlaky vy\u0161\u0161\u00ed ne\u017e u otok\u016f \u010dist\u011b \u017eiln\u00ed etiologie.\u00a0V\u011bt\u0161inou se jedn\u00e1 o tlaky kolem 45 mm Hg i v\u00edce,<br \/>\npouze u pacient\u016f s ni\u017e\u0161\u00edm ABI (ABI m\u00e9n\u011b ne\u017e 0,5)\u00a0nebo p\u0159i subjektivn\u00ed nesn\u00e1\u0161enlivosti vy\u0161\u0161\u00edch tlak\u016f\u00a0lze aplikovat hodnoty ni\u017e\u0161\u00ed. U pacient\u016f s lymfed\u00e9mem v\u0161ak b\u00fdv\u00e1 m\u011b\u0159en\u00ed ABI problematick\u00e9. L\u00e9\u010dba\u00a0je dlouhodob\u00e1 a v\u011bt\u0161inou se po n\u011bkolika m\u011bs\u00edc\u00edch\u00a0p\u0159ech\u00e1z\u00ed z obinadel ke KP. V\u00fdjimku tvo\u0159\u00ed pacienti s intoleranc\u00ed KP a s k\u0159ehkou k\u016f\u017e\u00ed, kter\u00e1 se p\u0159i aplikaci KP po\u0161kozuje.\u00a0Velmi d\u016fle\u017eit\u00e1 je kvalita pun\u010doch. Kompresivn\u00ed\u00a0pun\u010dochy mohou m\u00edt ni\u017e\u0161\u00ed ne\u017e o\u017eadovan\u00fd tlak\u00a0nebo i obr\u00e1cen\u00e9 tlakov\u00e9 gradienty, co\u017e zp\u016fsobuje\u00a0\u017eiln\u00ed kongesci a zvy\u0161uje riziko vzniku H\u017dT.<\/li>\n<\/ul>\n<p><!--nextpage--><\/p>\n<h3>10.5 \u017diln\u00ed malfomace, hemangiomy a kombinovan\u00e9 c\u00e9vn\u00ed malformace<\/h3>\n<h4>10.5.1 Klasifikace, histologie, patofyziologie<\/h4>\n<p style=\"text-align: justify;\">N\u00e1zvoslov\u00ed u\u017e\u00edvan\u00e9 pro c\u00e9vn\u00ed anom\u00e1lie bylo dlouho chaotick\u00e9 s nejednotnou nomenklaturou a chyb\u011bj\u00edc\u00edm uniformn\u00edm klasifika\u010dn\u00edm syst\u00e9mem. L\u00e9ka\u0159i popisovali r\u016fzn\u00e9 c\u00e9vn\u00ed anom\u00e1lie charakterizovan\u00e9 posti\u017een\u00edm k\u016f\u017ee, m\u011bkk\u00fdch tk\u00e1n\u00ed, krevn\u00edch a lymfatick\u00fdch c\u00e9v. Pro omezen\u00e9 diagnostick\u00e9 mo\u017enosti v minulosti \u010dasto unikala anatomick\u00e1 a patofyziologick\u00e1 podstata t\u011bchto onemocn\u011bn\u00ed, a proto byly opisov\u00e1ny a klasifikov\u00e1ny pouze na z\u00e1klad\u011b klinick\u00e9ho n\u00e1lezu (nap\u0159. <i>naevus f lammeus<\/i>, skvrny bar vy portsk\u00e9ho v\u00edna) a ozna\u010dov\u00e1ny jm\u00e9ny l\u00e9ka\u0159\u016f, kte\u0159\u00ed je popsali. Takov\u00e9 pojmenov\u00e1n\u00ed neposkytovalo \u017e\u00e1dnou informaci o etiologii, anatomii ani o patofyziologii c\u00e9vn\u00edch anom\u00e1li\u00ed. V roce 1982 Mulliken a Glowacki zavedli prvn\u00ed modern\u00ed jednoduchou klasifikaci zalo\u017eenou\u00a0na klinick\u00fdch, histochemick\u00fdch, cytologick\u00fdch krit\u00e9ri\u00edch a biologick\u00e9m chov\u00e1n\u00ed malformac\u00ed (Mulliken,\u00a01982). C\u00e9vn\u00ed malformace souborn\u011b ozna\u010dovan\u00e9 jako\u00a0\u201ec\u00e9vn\u00ed mate\u0159sk\u00e1 znam\u00e9nka\u201c rozd\u011blili na dv\u011b skupiny \u2013 na <b>vrozen\u00e9 c\u00e9vn\u00ed malformace a hemangiomy<\/b>.<\/p>\n<p style=\"text-align: justify;\">Vrozen\u00e9 c\u00e9vn\u00ed malformace d\u00e1le klasifikovali na n\u00edzko-pr\u016ftokov\u00e9 (\u017eiln\u00ed, kapil\u00e1rn\u00ed a lymfatick\u00e9 malformace) a vysoko-pr\u016ftokov\u00e9 l\u00e9ze (arteri\u00e1ln\u00ed malformace,\u00a0arterioven\u00f3zn\u00ed malformace a arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble)\u00a0(tab. 1). Z hlediska klinick\u00e9 medic\u00edny byla sice tato\u00a0klasifikace u\u017eite\u010dn\u00e1, ale proto\u017ee v sob\u011b kombinovala\u00a0r\u016fzn\u00e1 tradi\u010dn\u00ed pojmenov\u00e1n\u00ed, st\u00e1le byla nep\u0159esn\u00e1 a t\u011b\u017ekop\u00e1dn\u00e1. Mullikenovu klasifikaci bylo nutn\u00e9 je\u0161t\u011b d\u00e1le\u00a0upravit a doplnit. Tuto \u00falohu splnily ISSVA klasifikace\u00a0a Hambursk\u00e1 klasifikace.<\/p>\n<p>ISSVA klasifikace (International Society for the Study of Vascular Anomalies, \u0158\u00edm 1996) rozd\u011bluje\u00a0c\u00e9vn\u00ed anom\u00e1lie na <b>vrozen\u00e9 c\u00e9vn\u00ed malformace <\/b>(angiodysplazie \u2013 star\u0161\u00ed ozna\u010den\u00ed) <b>a na c\u00e9vn\u00ed tumory\u00a0<\/b>(neonat\u00e1ln\u00ed nebo d\u011btsk\u00e9 hemangiomy a ostatn\u00ed tumory). <b>Hambursk\u00e1 klasifikace <\/b>podrobn\u011b klasifikuje\u00a0vrozen\u00e9 c\u00e9vn\u00ed malformace do \u0161esti typ\u016f a n\u011bkolika\u00a0anatomicko-embryologick\u00fdch forem na z\u00e1klad\u011b modern\u00edch diagnostick\u00fdch metod. Sou\u010d\u00e1st\u00ed vrozen\u00fdch\u00a0c\u00e9vn\u00edch malformac\u00ed (v\u00fdvojov\u00fdch anom\u00e1li\u00ed perifern\u00edho\u00a0c\u00e9vn\u00edho syst\u00e9mu) jsou tak\u00e9 \u017eiln\u00ed malformace (tab. 2).Od hemangiom\u016f se vrozen\u00e9 c\u00e9vn\u00ed malformace li\u0161\u00ed\u00a0anatomicky, histologicky, patofyziologicky, progn\u00f3zou, sv\u00fdm klinick\u00fdm chov\u00e1n\u00edm a l\u00e9\u010dbou. Proto je nutn\u00e9 tyto dv\u011b nozologick\u00e9 jednotky p\u0159esn\u011b rozli\u0161ovat\u00a0(Lee, 2007, Lee, 2009).<\/p>\n<p>Novorozeneck\u00e9 nebo d\u011btsk\u00e9 hemangiomy jsou c\u00e9vn\u00ed tumor y vych\u00e1zej\u00edc\u00ed z endoteli\u00e1ln\u00edch bun\u011bk s omezen\u00fdm r\u016fstov\u00fdm potenci\u00e1lem. Obvykle se objevuj\u00ed v \u010dasn\u00e9m novorozeneck\u00e9m obdob\u00ed. Maj\u00ed sv\u016fj vlastn\u00ed r\u016fstov\u00fd cyklus charakterizovan\u00fd prolifera\u010dn\u00ed f\u00e1z\u00ed s rychl\u00fdm r\u016fstem, po kter\u00e9 n\u00e1sleduje involu\u010dn\u00ed f\u00e1ze pomal\u00e9 regrese. Kapil\u00e1rn\u00ed nebo kavern\u00f3zn\u00ed hemangiomy jsou term\u00edny ozna\u010duj\u00edc\u00ed pouze lokalizaci hemangiom\u016f.<\/p>\n<p>Prevalence <b>vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed <\/b>v populaci je asi 1,2\u20131,5%. P\u0159ibli\u017en\u011b dv\u011b t\u0159etiny jsou tvo\u0159en\u00e9 p\u0159ev\u00e1\u017en\u011b \u017eiln\u00edmi malformacemi a dal\u0161\u00ed \u010dtvrtina l\u00e9z\u00ed je \u00fapln\u011b nebo \u00a0\u00e1ste\u010dn\u011b lymfatick\u00e9ho p\u016fvodu. Vrozen\u00e9 c\u00e9vn\u00ed malformace se u lid\u00ed objevuj\u00ed sporadicky, bez rodinn\u00e9 z\u00e1t\u011b\u017ee, i kdy\u017e n\u011bkter\u00e9 jsou autozom\u00e1ln\u011b dominantn\u011b d\u011bdi\u010dn\u00e9. Spolu s nimi se vyskytuj\u00ed n\u011bkter\u00e9 dal\u0161\u00ed poruchy, zejm\u00e9na extravaskul\u00e1rn\u00ed: venost\u00e1za, defekty v\u00fdvoje skeletu, ischemie, koagulopatie, diseminovan\u00e1 intravaskul\u00e1rn\u00ed koagulopatie (DIC), srde\u010dn\u00ed selh\u00e1n\u00ed a p\u0159ed\u010dasn\u00e1 \u00famrt\u00ed. Vrozen\u00e9 c\u00e9vn\u00ed malformace jsou p\u0159\u00edtomn\u00e9 ji\u017e p\u0159i narozen\u00ed, i kdy\u017e nemus\u00ed b\u00fdt patrn\u00e9. Postihuj\u00ed stejn\u011b ob\u011b pohlav\u00ed. Vyv\u00edjej\u00ed se jako d\u016fsledek abnorm\u00e1ln\u00ed <b>vaskulogeneze <\/b>(vznik c\u00e9v <i>de novo <\/i>b\u011bhem embryogeneze, t\u00fdk\u00e1 se v\u0161ech c\u00e9v) a <b>angiogeneze <\/b>(novotvorba c\u00e9v z ji\u017e preexistuj\u00edc\u00edch c\u00e9v b\u011bhem v\u00fdvoje, z\u00e1n\u011btu, hojen\u00ed, p\u0159i r\u016fstu n\u00e1dor\u016f atd., t\u00fdk\u00e1 se nej\u010dast\u011bji kapil\u00e1r). Vznikaj\u00ed zastaven\u00edm v\u00fdvoje posti\u017een\u00fdch c\u00e9v b\u011bhem embryogeneze a fet\u00e1ln\u00edho v\u00fdvoje. C\u00e9va ustrne ve sv\u00e9m v\u00fdvoji, ale roste d\u00e1l spolu s cel\u00fdm organismem. Vrozen\u00e9 c\u00e9vn\u00ed malformace jsou tvo\u0159en\u00e9 norm\u00e1ln\u00edmi, stabiln\u00edmi, vyzr\u00e1l\u00fdmi, ploch\u00fdmi, endoteli\u00e1ln\u00edmi bu\u0148kami s fyziologick\u00fdm r\u016fstov\u00fdm cyklem, bez zn\u00e1mek hyperplazie.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td>Tabulka 1<br \/>\nMullikenova klasifikace c\u00e9vn\u00edch anom\u00e1li\u00ed (hemangiom\u016f a vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed) z roku 1982<br \/>\n(podle Ethunandana, 2006)<\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Hemangiomy\n<ul>\n<li>povrchov\u00e9 (kapil\u00e1rn\u00ed hemangiomy)<\/li>\n<li>hlubok\u00e9 (kavern\u00f3zn\u00ed hemangiomy)<\/li>\n<li>sm\u00ed\u0161en\u00e9 (kapil\u00e1rn\u011b-kavern\u00f3zn\u00ed hemangiomy)<\/li>\n<\/ul>\n<\/li>\n<li>Vrozen\u00e9 c\u00e9vn\u00ed malformace\n<ul>\n<li>jednoduch\u00e9 l\u00e9ze<\/li>\n<li>n\u00edzko-pr\u016ftokov\u00e9 malformace (\u017eiln\u00ed a lymfatick\u00e9 malformace)<\/li>\n<li>kapil\u00e1rn\u00ed malformace (kapil\u00e1rn\u00ed hemangiomy)<\/li>\n<li>\u017eiln\u00ed malformace<\/li>\n<li>lymfatick\u00e9 malformace (lymfangiomy, cystick\u00fd hygrom*)<\/li>\n<li>vysoko-pr\u016ftokov\u00e9 malformace (arteri\u00e1ln\u00ed a kapil\u00e1rn\u00ed malformace)<\/li>\n<li>kombinovan\u00e9 c\u00e9vn\u00ed malformace (arterioven\u00f3zn\u00ed malformace, lymfoven\u00f3zn\u00ed malformace, ostatn\u00ed kombinace)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><em>* hygrom \u2013 dutina vypln\u011bn\u00e1 tekutinou<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td>\n<p class=\"s34\">Tabulka 2<br \/>\nModifikovan\u00e1 Hambursk\u00e1 klasifikace vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed<br \/>\n(Hamburg 1988, Denver 1992, Soul 1996) (Lee, 2007)<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td>A. Typy vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed podle p\u0159eva\u017euj\u00edc\u00ed c\u00e9vn\u00ed struktury<\/p>\n<ul>\n<li>P\u0159ev\u00e1\u017en\u011b arteri\u00e1ln\u00ed malformace<\/li>\n<li>P\u0159ev\u00e1\u017en\u011b \u017eiln\u00ed malformace<\/li>\n<li>P\u0159ev\u00e1\u017en\u011b arterioven\u00f3zn\u00ed (AV) zkratov\u00e9 malformace<\/li>\n<li>P\u0159ev\u00e1\u017en\u011b kapil\u00e1rn\u00ed malformace<\/li>\n<li>P\u0159ev\u00e1\u017en\u011b lymfatick\u00e9 malformace<\/li>\n<li>Kombinovan\u00e9 c\u00e9vn\u00ed malformace = hemolymfatick\u00e9 malformace (KTS, KTWS)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td>B. Formy vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed (anatomick\u00e9\/embryologick\u00e9 podtypy)<\/p>\n<ul>\n<li>1. Nekmenov\u00e9 formy (\u010dasn\u00e9 embryologick\u00e9 l\u00e9ze)\n<ul>\n<li>\u015c\u015c Difuzn\u00ed, infiltruj\u00edc\u00ed formy<\/li>\n<li>\u015c\u015c Lokalizovan\u00e9, limitovan\u00e9 formy<\/li>\n<\/ul>\n<\/li>\n<li>2. Kmenov\u00e9 formy (pozd\u011bj\u0161\u00ed fet\u00e1ln\u00ed l\u00e9ze)\n<ul>\n<li>Obstrukce nebo z\u00fa\u017een\u00ed\n<ul>\n<li>nezral\u00e9, ne\u00fapln\u011b nebo nadm\u011brn\u011b vyvinut\u00e9 c\u00e9vy = hypoplazie, aplazie, hyperplazie<\/li>\n<li>defektn\u00ed c\u00e9vy s obstrukc\u00ed \u010di sten\u00f3zou \u2013 atr\u00e9zie, s\u00ed\u0165ka, ostruha, anulus, septum, membr\u00e1na, koarktace<\/li>\n<\/ul>\n<\/li>\n<li>Dilatace\n<ul>\n<li>lokalizovan\u00e1 (aneuryzma)<\/li>\n<li>difuzn\u00ed (ekt\u00e1zie)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><em>Zkratky: KTS = Klippel\u016fv-Trenaunay\u016fv syndrom, KTWS = Klippel\u016fv-Trenaunay\u016fv-Weber\u016fv syndrom<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td>Tabulka 3Diagnostika \u017eiln\u00edch malformac\u00ed (Lee, 2009)<\/td>\n<\/tr>\n<tr>\n<td>1. Klinick\u00e9 vy\u0161et\u0159en\u00ed<\/p>\n<ul>\n<li>detailn\u00ed palpace pulzu<\/li>\n<li>p\u00e1tr\u00e1n\u00ed po otoc\u00edch<\/li>\n<li>ko\u017en\u00ed zm\u011bny (pigmentace, ulcerace)<\/li>\n<li>varixy<\/li>\n<li>zv\u011bt\u0161en\u00ed\/prodlou\u017een\u00ed kon\u010detin<\/li>\n<li>prstn\u00ed anom\u00e1lie<\/li>\n<li>asymetrick\u00fd r\u016fst r\u016fzn\u00fdch \u010d\u00e1st\u00ed t\u011bla<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td>2. Neinvazivn\u00ed vy\u0161et\u0159en\u00ed<\/p>\n<ul>\n<li>ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed (metoda prvn\u00ed volby)<\/li>\n<li>pletyzmografie<\/li>\n<li>nativn\u00ed rentgen (malformace skeletu, flebolity v m\u011bkk\u00fdch tk\u00e1n\u00edch)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td>3. Miniinvazivn\u00ed vy\u0161et\u0159en\u00ed<\/p>\n<ul>\n<li>CT venografie (velk\u00e9 \u017e\u00edly b\u0159icha, hrudn\u00edku a p\u00e1nve)<\/li>\n<li>MR a MR venografie (doporu\u010den\u00e9 vy\u0161et\u0159en\u00ed k potvrzen\u00ed rozsahu a typu malformac\u00ed, pro ur\u010den\u00ed vy\u017eivuj\u00edc\u00edch a dr\u00e9nuj\u00edc\u00edch c\u00e9v, k rozli\u0161en\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed \/sval, tuk\/ a c\u00e9vn\u00edch struktur)<\/li>\n<li>celot\u011blov\u00e1 scintigrafie (screening v\u00edce\u010detn\u00fdch \u017eiln\u00edch malformac\u00ed roztrou\u0161en\u00fdch v t\u011ble, rutinn\u00ed sledov\u00e1n\u00ed malformac\u00ed bez l\u00e9\u010dby a po l\u00e9\u010db\u011b, vylou\u010den\u00ed kombinovan\u00fdch<\/li>\n<li>venolymfatick\u00fdch malformac\u00ed)<\/li>\n<li>ransarteri\u00e1ln\u00ed plicn\u00ed perfuzn\u00ed scintigrafie (vylou\u010den\u00ed kombinovan\u00fdch AV malformac\u00ed)<\/li>\n<li>radionuklidov\u00e1 lymfoscintigrafie (dg. prim\u00e1rn\u00edch lymfatick\u00fdch malformac\u00ed \u2013 prim\u00e1rn\u00ed lymfed\u00e9m)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td>4. Invazivn\u00ed vy\u0161et\u0159en\u00ed (ascendentn\u00ed, descendentn\u00ed a selektivn\u00ed flebografie, arteriografie, p\u0159\u00edm\u00e1 perkut\u00e1nn\u00ed punk\u010dn\u00ed angiografie \u2013 nevyu\u017e\u00edvaj\u00ed se v diagnostice, ale p\u0159ed pl\u00e1novanou chirurgickou nebo endovaskul\u00e1rn\u00ed l\u00e9\u010dbou)<\/td>\n<\/tr>\n<tr>\n<td>5. Vy\u0161et\u0159en\u00ed krve (D-dim\u00e9ry, fibrinogen, aPTT, INR, krevn\u00ed obraz, POZOR: rozs\u00e1hl\u00e9 \u017eiln\u00ed malformace a n\u011bkter\u00e9 c\u00e9vn\u00ed tumory jsou spojen\u00e9 s chronickou formou DIC)<\/td>\n<\/tr>\n<tr>\n<td>6. Histopatologick\u00e9 vy\u0161et\u0159en\u00ed \u2013 odli\u0161en\u00ed n\u011bkter\u00fdch c\u00e9vn\u00edch tumor\u016f (nap\u0159. dif. dg. neinvoluj\u00edc\u00edho hemangiomu a AV malformace)<\/td>\n<\/tr>\n<tr>\n<td>7. Imunohistochemick\u00e9 vy\u0161et\u0159en\u00edPodle modifikovan\u00e9 Hambursk\u00e9 klasifikace je ka\u017ed\u00fd typ c\u00e9vn\u00ed malformace (arteri\u00e1ln\u00ed, ven\u00f3zn\u00ed atd., viz tab. 2) d\u00e1le klasifikov\u00e1n jako nekmenov\u00e1 nebo kmenov\u00e1 forma na z\u00e1klad\u011b dosa\u017een\u00e9ho v\u00fdvojov\u00e9ho stadia.\u00a0<b>Nekmenov\u00e1 forma (p\u0159edkmenov\u00e1 embryon\u00e1ln\u00ed l\u00e9ze)\u00a0<\/b>vznik\u00e1, kdy\u017e se v\u00fdvoj c\u00e9v zastav\u00ed v \u010dasn\u00e9m obdob\u00ed embryon\u00e1ln\u00edho v\u00fdvoje, na \u00farovni primitivn\u00ed retikul\u00e1rn\u00ed s\u00edt\u011b utv\u00e1\u0159ej\u00edc\u00ed c\u00e9vn\u00ed syst\u00e9m. Pokud se v\u00fdvoj c\u00e9vy zastav\u00ed pozd\u011bji, ve fet\u00e1ln\u00edm obdob\u00ed, na \u00farovni tvorby c\u00e9vn\u00edch kmen\u016f, vznikaj\u00ed\u00a0<b>kmenov\u00e9 formy vrozen\u00fdch c\u00e9vn\u00edch malformac\u00ed (postkmenov\u00e9 fet\u00e1ln\u00ed l\u00e9ze).<\/b><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Nekmenov\u00e9 l\u00e9ze jsou tvo\u0159en\u00e9 zbytky mezenchym\u00e1ln\u00edch bun\u011bk embr yon\u00e1ln\u00edho mezodermu (angioblasty), kter\u00e9 jsou schopn\u00e9 r\u016fstu a proliferace po vnit\u0159n\u00ed (nap\u0159. menarch\u00e9, t\u011bhotenstv\u00ed, hormony)\u00a0nebo zevn\u00ed (nap\u0159. trauma, operace) stimulaci. Riziko recidivy je zde proto vysok\u00e9. Kmenov\u00e9 l\u00e9ze ji\u017e nemaj\u00ed charakter embryon\u00e1ln\u00edho mezodermu s jeho r\u016fstov\u00fdm a prolifera\u010dn\u00edm potenci\u00e1lem. Jsou tedy spojen\u00e9 s minim\u00e1ln\u00edm rizikem recidivy.<br \/>\nSpr\u00e1vn\u00e1 a p\u0159esn\u00e1 diagnostika pacient\u016f s \u017eiln\u00edmi malformacemi je velmi d\u016fle\u017eit\u00e1. Ve sv\u011bt\u011b je prosazov\u00e1na <b>koncepce multidisciplin\u00e1rn\u00edho t\u00fdmov\u00e9ho p\u0159\u00edstupu <\/b>zam\u011b\u0159en\u00e1 na prevenci a kontrolu recidivy\/perzistence malformac\u00ed s minimem komplikac\u00ed. V diagnostice \u017eiln\u00edch malformac\u00ed se uplat\u0148uje klinick\u00e9 vy\u0161et\u0159en\u00ed, neinvazivn\u00ed metody, miniinvazivn\u00ed metody, invazivn\u00ed metody, krevn\u00ed vy\u0161et\u0159en\u00ed, histopatologick\u00e9 a imunohistochemick\u00e9 vy\u0161et\u0159en\u00ed. V\u011bt\u0161inou vysta\u010d\u00edme s klinick\u00fdm vy\u0161et\u0159en\u00edm, neinvazivn\u00edmi a miniinvazivn\u00edmi metodami (tab. 3).<\/p>\n<h4>10.5.2 Hemangiomy<\/h4>\n<p>Objevuj\u00ed se v\u011bt\u0161inou v pr vn\u00edch n\u011bkolika t\u00fddnech \u017eivota, nikoliv v\u0161ak ji\u017e p\u0159i narozen\u00ed. Mezi pacienty p\u0159eva\u017euje \u017eensk\u00e9 pohlav\u00ed (3 : 1). Nejsou pova\u017eov\u00e1ny za prav\u00e9 c\u00e9vn\u00ed malformace, ale za c\u00e9vnat\u00e9 n\u00e1dory, nej\u010dast\u011bj\u0161\u00ed benign\u00ed n\u00e1dory d\u011btsk\u00e9ho v\u011bku. Histologicky zji\u0161\u0165ujeme hyperplazii endotelu. Tyto n\u00e1dory se manifestuj\u00ed b\u011bhem n\u011bkolika prvn\u00edch t\u00fddn\u016f \u017eivota, kdy v proliferativn\u00ed f\u00e1zi sv\u00e9ho v\u00fdvoje rostou rychle a disproporcion\u00e1ln\u011b vzhledem k celkov\u00e9mu r\u016fstu d\u00edt\u011bte, n\u00e1sledn\u011b se pomalu, v pr\u016fb\u011bhu n\u011bkolika let, zmen\u0161uj\u00ed (involuce), tak\u017ee ve \u0161koln\u00edm v\u011bku jsou ji\u017e v\u011bt\u0161inou kompletn\u011b resorbov\u00e1ny.<\/p>\n<p>Hemangiomy jsou dob\u0159e ohrani\u010den\u00e9 n\u00e1dory. V\u00edce ne\u017e v polovin\u011b p\u0159\u00edpad\u016f rostou na hlav\u011b a krku a p\u0159ibli\u017en\u011b v 20\u201325% jsou lokalizov\u00e1ny na kon\u010detin\u00e1ch.<\/p>\n<p>Klinick\u00fd v\u00fdznam hemangiom\u016f spo\u010d\u00edv\u00e1 v jejich lokalizaci a doprovodn\u00fdch komplikac\u00edch. Nebezpe\u010dn\u00e9 jsou kraniofaci\u00e1ln\u00ed a orofarynge\u00e1ln\u00ed hemangiomy. Orofarynge\u00e1ln\u00ed l\u00e9ze jsou spojen\u00e9 s poruchami s\u00e1n\u00ed a p\u0159\u00edjmu potravy nebo s obstrukc\u00ed d\u00fdchac\u00edch cest. Viscer\u00e1ln\u00ed hemangiomy mohou b\u00fdt p\u0159\u00ed\u010dinou m\u011bstnav\u00e9ho srde\u010dn\u00edho selh\u00e1n\u00ed ohro\u017euj\u00edc\u00edho d\u00edt\u011b na \u017eivot\u011b. Ko\u017en\u00ed a slizni\u010dn\u00ed hemangiomy n\u011bkdy v proliferativn\u00ed f\u00e1zi exulceruj\u00ed a krv\u00e1cej\u00ed.<br \/>\nK l\u00e9\u010db\u011b se p\u0159istupuje pouze u komplikovan\u00fdch hemangiom\u016f. V prolifera\u010dn\u00ed f\u00e1zi jsou \u00fa\u010dinn\u00e9 celkov\u011b pod\u00e1van\u00e9 steroidy a laserov\u00e1 terapie. Dal\u0161\u00ed volbou je limitovan\u00e1 chirurgick\u00e1 excize. Krv\u00e1cej\u00edc\u00ed ko\u017en\u00ed a slizni\u010dn\u00ed hemangiomy lze v prvn\u00ed f\u00e1zi o\u0161et\u0159it lok\u00e1ln\u011b, p\u0159i pokra\u010duj\u00edc\u00edm krv\u00e1cen\u00ed je nutn\u00e9 chirurgick\u00e9 odstran\u011bn\u00ed.<\/p>\n<h6>MERRITTOV\u00c9-KASABACH\u016eV SYNDROM (ANAEMIA HAEMOLY TICA MICROANGIOPATHICA, THROMBOPENIA-HAEMANGIOMA)<\/h6>\n<p>D\u011bdi\u010dn\u00e9 velk\u00e9 kavern\u00f3zn\u00ed hemangiomy s trombocytopenickou purpurou. V krvi je konzump\u010dn\u00ed trombocytopenie a \u010dasto i an\u00e9mie. Trombocytopenie vznik\u00e1 spot\u0159ebov\u00e1n\u00edm (konzumpc\u00ed) trombocyt\u016f p\u0159i tvorb\u011b tromb\u016f vypl\u0148uj\u00edc\u00edch rozs\u00e1hl\u00e9 kavern\u00f3zn\u00ed hemangiomy. Krv\u00e1cen\u00ed do k\u016f\u017ee, sliznic a hemangiom\u016f je p\u0159\u00ed\u010dinou an\u00e9mie. V kostn\u00ed d\u0159eni jsou v d\u016fsledku z\u00e1va\u017en\u00e9 trombocytopenie zmno\u017een\u00e9 megakaryocyty s poruchou zr\u00e1n\u00ed. Klinicky b\u00fdvaj\u00ed zn\u00e1mky hemoragick\u00e9 diat\u00e9zy a na k\u016f\u017ei se objevuj\u00ed petechie, kter\u00e9 m\u00edsty spl\u00fdvaj\u00ed do hmatn\u00e9, ohrani\u010den\u00e9, r\u016fzn\u011b velik\u00e9 purpury. Jindy hemangiomy trvale zevn\u011b krv\u00e1cej\u00ed nebo se rychle zv\u011bt\u0161uj\u00ed p\u0159i vnit\u0159n\u00edm krv\u00e1cen\u00ed do l\u00e9ze.<\/p>\n<p>Podp\u016frnou l\u00e9\u010dbou jsou krevn\u00ed transfuze a syst\u00e9mov\u00e9 pod\u00e1v\u00e1n\u00ed steroid\u016f. P\u0159evody trombocyt\u016f nemaj\u00ed v\u00fdznam pro jejich pokra\u010duj\u00edc\u00ed sekvestraci a konzumpci v hemangiomu. Krv\u00e1cej\u00edc\u00ed l\u00e9ze lze o\u0161et\u0159it chirurgicky\u00a0nebo embolizac\u00ed gelem, metakryl\u00e1tov\u00fdmi lepidly \u010di kovovou spir\u00e1lou, p\u0159\u00edpadn\u011b aplikac\u00ed alkoholu, a to bu\u010f samostatn\u011b, nebo v kombinaci s chirurgick\u00fdm v\u00fdkonem. U \u017eivot ohro\u017euj\u00edc\u00edch hemangiom\u016f se prov\u00e1d\u00ed plazmafer\u00e9za nebo chemoterapie (Rodriguez, 2009).<\/p>\n<h4>10.5.3 P\u0159ev\u00e1\u017en\u011b \u017eiln\u00ed malformace<\/h4>\n<p>\u017diln\u00ed malformace jsou v\u00fdvojov\u00e9 anom\u00e1lie, vrozen\u00e9 defekty \u017eiln\u00edho syst\u00e9mu, nej\u010dast\u011bj\u0161\u00ed vrozen\u00e9 c\u00e9vn\u00ed malformace (tab. 1 a 2). Ve dvou t\u0159etin\u00e1ch p\u0159\u00edpad\u016f postihuj\u00ed kon\u010detiny. N\u011bkdy jsou nespr\u00e1vn\u011b ozna\u010dov\u00e1ny jako kavern\u00f3zn\u00ed hemangiomy, flebangiomy nebo \u017eiln\u00ed angiomy. Jedn\u00e1 se o zm\u011bny pr\u016fb\u011bhu, ulo\u017een\u00ed a po\u010dtu \u017eil, \u017eiln\u00edch chlopn\u00ed, o nedostate\u010dn\u00fd v\u00fdvoj \u017eil nebo o jejich abnorm\u00e1ln\u00ed utv\u00e1\u0159en\u00ed b\u011bhem ontogeneze (ektazie, venomegalie, spongiformn\u00ed \u017eiln\u00ed malformace) (tab. 4). Mohou b\u00fdt limitov\u00e1ny pouze na k\u016f\u017ei a podko\u017e\u00ed nebo postihovat tak\u00e9 svaly, kosti a klouby (tab. 5). Jsou lokalizovan\u00e9 \u010di generalizovan\u00e9 (tab. 6). Ve v\u00edce ne\u017e 35% p\u0159\u00edpad\u016f jsou spojen\u00e9 s kostn\u00edmi abnormalitami.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellpadding=\"0\" class=\"CSSTableGenerator\">\n<tbody>\n<tr>\n<td>Tabulka 4Klasifikace r\u016fzn\u00fdch forem \u017eiln\u00edch malformac\u00ed podle modifikovan\u00e9 Hambursk\u00e9 klasifikace (Lee, 2009)<\/td>\n<\/tr>\n<tr>\n<td><strong>A. Nekmenov\u00e9 formy<\/strong><\/p>\n<ul>\n<li>Infiltruj\u00edc\u00ed, difuzn\u00ed\n<ul>\n<li>spongiformn\u00ed \u017eiln\u00ed malformace (flebangiomy)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><strong>B. Kmenov\u00e9 formy<\/strong><\/p>\n<ul>\n<ol>\n<li>zm\u011bny pr\u016fb\u011bhu, polohy a po\u010dtu \u017eil<\/li>\n<\/ol>\n<ul>\n<ul>\n<li>chlopenn\u00ed anom\u00e1lie<\/li>\n<li><strong>Obstrukce nebo sten\u00f3za<\/strong>\n<ul>\n<li>nevyvinut\u00e9 a nezral\u00e9 \u017e\u00edly \u2013 ageneze, aplazie, avalvulie<\/li>\n<li>ne\u00fapln\u011b nebo nadm\u011brn\u011b vyvinut\u00e9 hlavn\u00ed axi\u00e1ln\u00ed \u017e\u00edly \u2013 hypoplazie, hyperplazie<\/li>\n<li>obstukce \u010di sten\u00f3za \u017eil \u2013 atr\u00e9zie, \u017eiln\u00ed s\u00ed\u0165ka, ostruha, anulus, septum, membr\u00e1na, koarktace<\/li>\n<\/ul>\n<\/li>\n<li><strong> Dilatace<\/strong>\n<ul>\n<li>lok\u00e1ln\u00ed dilatace \u2013 \u017eiln\u00ed aneuryzma<\/li>\n<li>difuzn\u00ed roz\u0161\u00ed\u0159en\u00ed \u2013 venektazie (flebektazie, venodilatace), venomegalie<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/ul>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table style=\"width: 100%;\" border=\"0\" cellpadding=\"0\" class=\"CSSTableGenerator\">\n<tbody>\n<tr>\n<td>Tabulka 5Subklasifikace \u017eiln\u00edch malformac\u00ed podle anatomick\u00e9 lokalizace (Lee, 2009)<\/td>\n<\/tr>\n<tr>\n<td>\n<ol>\n<li>Intraderm\u00e1ln\u00ed \u017eiln\u00ed malformace \u2013 vytv\u00e1\u0159ej\u00ed povrchov\u00e9 teleangiektazie<\/li>\n<li>\u017diln\u00ed malformace v podko\u017en\u00edm tuku<\/li>\n<li>\u017diln\u00ed malformace svalov\u00e9, kloubn\u00ed nebo v dal\u0161\u00edch org\u00e1nech<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table style=\"width: 100%;\" border=\"0\" cellpadding=\"0\" class=\"CSSTableGenerator\">\n<tbody>\n<tr>\n<td>Tabulka 6Subklasifikace \u017eiln\u00edch malformac\u00ed podle klinick\u00fdch projev\u016f (Lee, 2009)<\/td>\n<\/tr>\n<tr>\n<td>1. lokalizovan\u00e9 \u2013 obli\u010dej, trup, kon\u010detiny, mozek, m\u00edcha, pl\u00edce atd.2. generalizovan\u00e9 \u2013 prav\u00e1 difuzn\u00ed flebektazie (Bockenheimer)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><br \/>\nDEFINICE \u017dILN\u00cdCH MALFORMACI<\/p>\n<ul>\n<li><strong>Ageneze<br \/>\n<\/strong>Jde o <b>\u00fapln\u00e9 vrozen\u00e9 chyb\u011bn\u00ed \u017e\u00edly nebo \u017eiln\u00edho <\/b>segmentu, kdy se nevytvo\u0159il ani embryon\u00e1ln\u00ed\u00a0\u017eiln\u00ed z\u00e1klad. Nej\u010dast\u011bji se lze setkat s agenez\u00ed doln\u00ed\u00a0dut\u00e9 \u017e\u00edly (prevalence 0,3\u20132%). Ageneze ky\u010deln\u00edch,\u00a0stehenn\u00edch a podkolenn\u00edch \u017eil je mnohem vz\u00e1cn\u011bj\u0161\u00ed. Asi u jedn\u00e9 t\u0159etiny pacient\u016f s Klippelov\u00fdm-Trenaunayov\u00fdm syndromem se m\u016f\u017ee vyskytnout\u00a0ageneze hlubok\u00e9 \u017e\u00edly na posti\u017een\u00e9 doln\u00ed kon\u010detin\u011b.<\/li>\n<li><strong>Aplazie<br \/>\n<\/strong>\u017d\u00edla nebo \u017eiln\u00ed segment nejsou vyvinut\u00e9. Z\u00e1klad \u017e\u00edly se sice nach\u00e1z\u00ed na obvykl\u00e9m m\u00edst\u011b, ale jeho velikost je minim\u00e1ln\u00ed a zachov\u00e1v\u00e1 si svou embryon\u00e1ln\u00ed strukturu. V b\u011b\u017en\u00e9 klinick\u00e9 praxi se ov\u0161em velice t\u011b\u017eko budeme rozhodovat mezi agenez\u00ed\u00a0a aplazi\u00ed, proto pokud p\u0159i rutinn\u00edm ultrazvukov\u00e9m vy\u0161et\u0159en\u00ed neprok\u00e1\u017eeme \u017e\u00edlu na jej\u00edm obvykl\u00e9m\u00a0m\u00edst\u011b, budeme mluvit o aplazii, nikoliv o agenezi,\u00a0proto\u017ee pro diagn\u00f3zu ageneze pot\u0159ebujeme histologick\u00e9 vy\u0161et\u0159en\u00ed, kter\u00e9 neprok\u00e1\u017ee ani embryon\u00e1ln\u00ed\u00a0z\u00e1klad p\u0159\u00edslu\u0161n\u00e9 \u017e\u00edly.<\/li>\n<li><strong>Hypoplazie<br \/>\n<\/strong>V\u00fdvoj \u017e\u00edly nebo \u017eiln\u00edho segmentu b\u011bhem ontogeneze je nedostate\u010dn\u00fd. Jedn\u00e1 se o m\u00e9n\u011b vyj\u00e1d\u0159enou\u00a0aplazii. <b>Prim\u00e1rn\u011b hypoplastick\u00e1 \u017e\u00edla je <\/b><strong>nedostate\u010dn\u011b<\/strong> vyvinut\u00e1, m\u00e1 men\u0161\u00ed kalibr ne\u017e obvykle, je\u00a0z\u00fa\u017een\u00e1, ale jej\u00ed struktura je norm\u00e1ln\u00ed. V klinick\u00e9\u00a0praxi se jedn\u00e1 o hypoplazii, pokud je kalibr posti\u017een\u00e9 \u017e\u00edly men\u0161\u00ed o v\u00edce ne\u017e 50% ve srovn\u00e1n\u00ed s kalibrem norm\u00e1ln\u011b vyvinut\u00e9 \u017e\u00edly. Se sekund\u00e1rn\u00ed \u017eiln\u00ed\u00a0hypoplazi\u00ed se setk\u00e1v\u00e1me po prod\u011blan\u00e9 tromb\u00f3ze.<br \/>\n\u017diln\u00ed hypoplazie v\u011bt\u0161inou nejsou pro sv\u00e9 nositele d\u016fle\u017eit\u00e9. V n\u011bkter\u00fdch p\u0159\u00edpadech ale mohou b\u00fdt\u00a0klinicky v\u00fdznamn\u00e9. T\u00fdk\u00e1 se to hlavn\u011b velk\u00e9 safeny.\u00a0Jako hypoplastick\u00e1 je velk\u00e1 safena ozna\u010dov\u00e1na tehdy, pokud nen\u00ed mo\u017en\u00e9 v kompartmentu velk\u00e9 safeny naj\u00edt \u017e\u00e1dnou \u017e\u00edlu. M\u016f\u017ee se jednat o hypoplazii<br \/>\ncel\u00e9 safeny, v\u011bt\u0161inou v\u0161ak nach\u00e1z\u00edme segment\u00e1ln\u00ed\u00a0hypoplazii. Segment\u00e1ln\u00ed hypoplazie velk\u00e9 safeny je\u00a0\u010dast\u00e1, m\u016f\u017ee dosahovat r\u016fzn\u00fdch rozm\u011br\u016f a m\u016f\u017eeme<br \/>\nji naj\u00edt na r\u016fzn\u00fdch m\u00edstech \u017e\u00edly.<\/li>\n<li><strong>Dysplazie<br \/>\n<\/strong>Jedn\u00e1 se o <b>komplexn\u00ed abnormalitu ve v\u00fdvoji \u017e\u00edly\u00a0<\/b>nebo skupiny \u017eil. Posti\u017een\u00e1 \u017e\u00edla se v\u00fdrazn\u011b odli\u0161uje\u00a0velikost\u00ed, strukturou a sv\u00fdm pr\u016fb\u011bhem (propojen\u00edm).<\/li>\n<li><strong>Atrofie<br \/>\n<\/strong>Jde <b>o zmen\u0161en\u00ed nebo po\u0161kozen\u00ed norm\u00e1ln\u011b <\/b><strong>vyvinut\u00e9 \u017e\u00edly<\/strong> nebo \u017eiln\u00edho segmentu v d\u016fsledku sekund\u00e1rn\u00edho degenerativn\u00edho procesu. Zm\u011bny \u017eiln\u00ed<br \/>\nst\u011bny maj\u00ed r\u016fzn\u00fd charakter, podle povahy degenerativn\u00edho procesu.<\/li>\n<li><strong>\u017diln\u00ed aneuryzma<br \/>\n<\/strong>\u017diln\u00ed aneuryzma je v\u00fdrazn\u00e1 <b>m\u00edstn\u00ed (lokalizova<\/b>n\u00e1) dilatace \u017eiln\u00edho segmentu, kter\u00e1 m\u00e1 kalibr\u00a0alespo\u0148 o 50% \u0161ir\u0161\u00ed ve srovn\u00e1n\u00ed s nedilatovanou\u00a0\u017eilou. M\u016f\u017ee m\u00edt vakovit\u00fd (sakul\u00e1rn\u00ed) nebo v\u0159etenovit\u00fd (fuziformn\u00ed) tvar. S \u017eiln\u00edmi aneuryzmaty\u00a0se setk\u00e1v\u00e1me p\u0159i vysoko-pr\u016ftokov\u00fdch poruch\u00e1ch\u00a0nebo u \u017eiln\u00edch malformac\u00ed. \u017diln\u00ed dilatace, kter\u00e9\u00a0prov\u00e1zej\u00ed arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble, p\u0159edstavuj\u00ed mechanismus kompenzuj\u00edc\u00ed velk\u00e9 t\u0159ec\u00ed s\u00edly p\u016fsob\u00edc\u00ed\u00a0na \u017eiln\u00ed st\u011bnu.<\/li>\n<li><strong>Venektazie (flebektazie, venodilatace), venome<\/strong><strong>galie<br \/>\n<\/strong>Jde-li o <b>difuzn\u00ed dilataci \u017e\u00edly<\/b>, jej\u00ed\u017e kalibr je <b>o v\u00edce\u00a0<\/b>ne\u017e 50% \u0161ir\u0161\u00ed ne\u017e kalibr nedilatovan\u00e9 \u017e\u00edly, mluv\u00edme <b>o venomegalii<\/b>. P\u0159i m\u00e9n\u011b vyj\u00e1d\u0159en\u00e9m <b>difuzn\u00edm\u00a0<\/b>roz\u0161\u00ed\u0159en\u00ed \u017e\u00edly, jej\u00ed\u017e kalibr nen\u00ed o v\u00edce ne\u017e 50% \u0161ir\u0161\u00ed ne\u017e kalibr nedilatovan\u00e9 \u017e\u00edly, mluv\u00edme o <b>venektazii<\/b>.<br \/>\nVenektazie a venomegalie mohou b\u00fdt vrozen\u00e9 nebo\u00a0z\u00edskan\u00e9. Nej\u010dast\u011bji se s nimi setk\u00e1v\u00e1me u ko\u017en\u00edch\u00a0\u017eil p\u0159i \u017eiln\u00ed insuficienci (mnoho\u010detn\u00e9 ektazie drobn\u00fdch intraderm\u00e1ln\u00edch \u017eil na doln\u00edch kon\u010detin\u00e1ch),\u00a0u pacient\u016f se Klippelov\u00fdm-Trenaunayov\u00fdm syndromem (venomegalie) nebo p\u0159i arterioven\u00f3zn\u00edch\u00a0spojk\u00e1ch. Na rozd\u00edl od venektazi\u00ed a venomegalie\u00a0jsou varixy nejenom dilatovan\u00e9, ale tak\u00e9 vinut\u00e9\u00a0ko\u017en\u00ed a podko\u017en\u00ed \u017e\u00edly.<\/li>\n<li><strong>Zdvojen\u00ed \u017e\u00edly (duplikace)<br \/>\n<\/strong>O skute\u010dn\u00e9m (prav\u00e9m) anatomick\u00e9m zdvojen\u00ed\u00a0mluv\u00edme pouze tehdy, pokud ob\u011b v\u011btve zdvojen\u00e9\u00a0\u017e\u00edly maj\u00ed stejn\u00fd pr\u016fb\u011bh (jsou paraleln\u00ed), topografii a vztahy k okoln\u00edm struktur\u00e1m \u2013 ke sval\u016fm, fasci\u00edm a tepn\u00e1m (nap\u0159. tibi\u00e1ln\u00ed \u017e\u00edly). Jejich kalibr p\u0159itom m\u016f\u017ee b\u00fdt stejn\u00fd nebo asymetrick\u00fd. Pokud jedna nebo n\u011bkolik \u017eil prob\u00edh\u00e1 paraleln\u011b s hlavn\u00ed \u017e\u00edlou, ale v r\u016fzn\u00fdch rovin\u00e1ch nebo kompartmentech kon\u010detiny, mluv\u00edme <b>pouze o funk\u010dn\u00edm zdvojen\u00ed <\/b>(nap\u0159. velk\u00e1 safena a p\u0159\u00eddatn\u00e9 velk\u00e9 safeny, kter\u00e9 nejsou v cel\u00e9 sv\u00e9 d\u00e9lce ulo\u017eeny v safenov\u00e9m kompartmentu).Duplikace \u017e\u00edly m\u016f\u017ee b\u00fdt \u00fapln\u00e1 nebo \u010d\u00e1ste\u010dn\u00e1. \u00dapln\u00e1 duplikace znamen\u00e1 zdvojen\u00ed \u017e\u00edly v cel\u00e9m jej\u00edm pr\u016fb\u011bhu, zat\u00edmco u \u010d\u00e1ste\u010dn\u00e9 duplikace jde o zdvojen\u00ed pouze v n\u011bkter\u00e9m segmentu nebo v n\u011bkolika segmentech. To znamen\u00e1, \u017ee \u017e\u00edla m\u016f\u017ee b\u00fdt zdvojen\u00e1 pouze v d\u00e9lce n\u011bkolika centimetr\u016f. Zdvojen\u00ed doln\u00ed dut\u00e9 \u017e\u00edly se vyskytuje u 0,2\u20133% populace, ale zdvojen\u00ed \u017eil doln\u00edch kon\u010detin je mnohem \u010dast\u011bj\u0161\u00ed. N\u011bkdy se m\u016f\u017eeme setkat i se t\u0159emi kmeny jedn\u00e9 \u017e\u00edly. V literatu\u0159e se dokonce uv\u00e1d\u00ed, \u017ee podkolenn\u00ed \u017e\u00edla je zdvojen\u00e1 a\u017e v 50% p\u0159\u00edpad\u016f.<\/li>\n<li><strong>Spongiformn\u00ed \u017eiln\u00ed malformace (flebangiomy)<br \/>\n<\/strong>Pat\u0159\u00ed do skupiny n\u00edzko-pr\u016ftokov\u00fdch \u017eiln\u00edch malformac\u00ed. Mohou vyvol\u00e1vat klinick\u00e9 p\u0159\u00edznaky svou ne\u0161\u0165astnou polohou, ovliv\u0148uj\u00edc\u00ed okoln\u00ed struktury (nervov\u00e9 svazky, smyslov\u00e9 org\u00e1ny apod.) a tak\u00e9 v\u00fdznamn\u00fdm krv\u00e1cen\u00edm.<\/li>\n<\/ul>\n<h4>10.5.4 Klinick\u00e9 projevy a diagnostika<\/h4>\n<p>N\u00edzko-pr\u016ftokov\u00e9 \u017eiln\u00ed malformace jsou p\u0159\u00edtomn\u00e9 ji\u017e p\u0159i narozen\u00ed, ale n\u011bkdy za\u010dnou b\u00fdt patrn\u00e9 a\u017e v pozd\u011bj\u0161\u00edm v\u011bku. \u017diln\u00ed malformace nebol\u00ed, jsou m\u011bkk\u00e9, namodral\u00e9 barvy, kter\u00e1 se zv\u00fdraz\u0148uje ve sv\u011b\u0161en\u00e9 poloze, lze do nich lehce vym\u00e1\u010dknout d\u016flek. Na rozd\u00edl od hemangiom\u016f nikdy neproliferuj\u00ed, nezmno\u017euj\u00ed se ani se nezmen\u0161uj\u00ed (neinvoluj\u00ed). Naopak b\u011bhem \u017eivota se pomalu a ne\u00faprosn\u011b zv\u011bt\u0161uj\u00ed, expanduj\u00ed, rostou spolu se sv\u00fdm nositelem a velikost zv\u011bt\u0161uj\u00ed t\u00e9\u017e p\u016fsoben\u00edm gravitace. Poran\u011bn\u00ed, puberta, n\u00e1stup menstruace a t\u011bhotenstv\u00ed mohou r\u016fst \u017eiln\u00ed malformace urychlit a asymptomatick\u00e9 l\u00e9ze se stanou symptomatick\u00fdmi. Trauma z\u0159ejm\u011b naru\u0161\u00ed p\u0159edt\u00edm stabiln\u00ed kolater\u00e1ln\u00ed syst\u00e9m a odmaskuje \u017eiln\u00ed malformaci. 7% pacient\u016f se \u017eiln\u00edmi malformacemi na doln\u00edch kon\u010detin\u00e1ch m\u00e1 zjevn\u00fd rozd\u00edl v jejich d\u00e9lce, u adolescent\u016f tak doch\u00e1z\u00ed ke vzniku skoli\u00f3zy.\u00a0Nejb\u011b\u017en\u011bj\u0161\u00edmi komplikacemi \u017eiln\u00edch malformaci jsou tromb\u00f3za, bolest, otok a zv\u011bt\u0161ov\u00e1n\u00ed malformace. N\u00e1hl\u00e9 zv\u011bt\u0161en\u00ed \u017eiln\u00ed malformace je vz\u00e1cn\u00e9. Doch\u00e1z\u00ed k n\u011bmu v d\u016fsledku krv\u00e1cen\u00ed uvnit\u0159 l\u00e9ze.<\/p>\n<p>Zm\u011bny pr\u016fb\u011bhu, polohy a po\u010dtu \u017eil maj\u00ed jenom z\u0159\u00eddka klinick\u00fd v\u00fdznam. Chlopenn\u00ed \u017eiln\u00ed anom\u00e1lie (aplazie nebo hypolazie \u017eiln\u00edch chlopn\u00ed) zpravidla vedou ke vzniku varix\u016f na horn\u00edch a doln\u00edch kon\u010detin\u00e1ch. \u010casto zji\u0161\u0165ujeme rodinnou z\u00e1t\u011b\u017e. <b>\u017diln\u00ed aplazie, hypoplazie nebo vrozen\u00e9 uz\u00e1v\u011bry hlubok\u00fdch \u017eil <\/b>jsou vz\u00e1cn\u00e9 a klinicky v\u00fdznamn\u00e9, proto\u017ee jsou v\u017edy symptomatick\u00e9 a \u010dasto spojen\u00e9 s abnormalitami skeletu, s varixy a kapil\u00e1rn\u00edmi ko\u017en\u00edmi malformacemi.<\/p>\n<h4>10.5.5 L\u00e9\u010dba a progn\u00f3za<\/h4>\n<p>L\u00e9\u010dba \u017eiln\u00edch malformac\u00ed z\u00e1vis\u00ed na symptomech a potenci\u00e1ln\u00edch komplikac\u00edch, kter\u00e9 jsou s nimi spojen\u00e9. Indikacemi k l\u00e9\u010db\u011b jsou m\u011bstnav\u00e9 srde\u010dn\u00ed selh\u00e1n\u00ed, ischemie, krv\u00e1cen\u00ed, ulcerace, funk\u010dn\u00ed posti\u017een\u00ed a kosmetick\u00e9 vady. L\u00e9\u010dba spo\u010d\u00edv\u00e1 v transkatetrov\u00fdch bolizac\u00edch, chirurgick\u00fdch exciz\u00edch a celo\u017eivotn\u00ed kompresi posti\u017een\u00fdch m\u00edst. Definitivn\u00ed l\u00e9\u010dba je mo\u017en\u00e1 pouze u pacient\u016f s ohrani\u010den\u00fdmi, povrchov\u00fdmi l\u00e9zemi. Pro kompletn\u00ed excizi je vhodn\u00fdch pouze 20\u201330% pacient\u016f se \u017eiln\u00edmi malformacemi.<\/p>\n<h6>P\u0158EV\u00c1\u017dN\u011a ARTERIOVEN\u00d3ZN\u00cd (AV) ZKRATOV\u00c9 MALFORMACE<\/h6>\n<p>Tento typ c\u00e9vn\u00edch malformac\u00ed je charakteristick\u00fd abnorm\u00e1ln\u00edm spojen\u00edm mezi tepnami a \u017e\u00edlami, kdy se krev dost\u00e1v\u00e1 z tepenn\u00e9ho \u0159e\u010di\u0161t\u011b p\u0159\u00edmo do \u017eil a obch\u00e1z\u00ed tak kapil\u00e1rn\u00ed s\u00ed\u0165. Arterioven\u00f3zn\u00ed zkrat se m\u016f\u017ee objevit na kter\u00e9koliv \u00farovni c\u00e9vn\u00edho stromu. Klinick\u00fd obraz je velmi \u0161irok\u00fd, ale na z\u00e1klad\u011b anatomick\u00e9 struktury lze rozli\u0161it t\u0159i hlavn\u00ed skupiny t\u011bchto malformac\u00ed: 1. kmenov\u00e9, 2. difuzn\u00ed a 3. lokalizovan\u00e9 (fok\u00e1ln\u00ed). Ka\u017ed\u00e1 arterioven\u00f3zn\u00ed malformace m\u016f\u017ee b\u00fdt hemodynamicky \u201ehyperaktivn\u00ed\u201c nebo \u201ehypoaktivn\u00ed\u201c.<\/p>\n<ul>\n<li>Kmenov\u00e9 arterioven\u00f3zn\u00ed malformace p\u0159edstavuj\u00ed dysembryoplazie ji\u017e diferencovan\u00fdch c\u00e9vn\u00edch kmen\u016f. Vych\u00e1zej\u00ed z hlavn\u00edch tepenn\u00fdch kmen\u016f, jsou obvykle lokalizovan\u00e9, ale \u010dasto b\u00fdvaj\u00ed posti\u017een\u00e9 tak\u00e9 sousedn\u00ed c\u00e9vy. Jde o hemodynamicky aktivn\u00ed a progresivn\u011b se zv\u011bt\u0161uj\u00edc\u00ed l\u00e9ze. \u010cast\u011bji se s nimi setk\u00e1me na horn\u00edch kon\u010detin\u00e1ch, hlav\u011b a krku ne\u017e na doln\u00edch kon\u010detin\u00e1ch a v p\u00e1nvi.<\/li>\n<li>Difuzn\u00ed arterioven\u00f3zn\u00ed malformace se objevuj\u00ed na kon\u010detin\u00e1ch, \u010dast\u011bji na doln\u00edch. Arterioven\u00f3zn\u00ed spojky jsou drobn\u00e9, ale je jich velk\u00e9 mno\u017estv\u00ed. Navzdory tomu jsou v\u0161ak hemodynamicky m\u00e9n\u011b aktivn\u00ed ne\u017e kmenov\u00e9 l\u00e9ze.<\/li>\n<li>Lokalizovan\u00e9 (fok\u00e1ln\u00ed) arterioven\u00f3zn\u00ed malformace jsou tvo\u0159en\u00e9 masou abnorm\u00e1ln\u00ed nadpo\u010detn\u00e9 tk\u00e1n\u011b a podobn\u011b jako difuzn\u00ed l\u00e9ze vznikaj\u00ed ze zbytk\u016f primitivn\u00ed kapil\u00e1rn\u00ed s\u00edt\u011b. Jejich hemodynamick\u00e1 aktivita je r\u016fzn\u00e1, v\u011bt\u0161ina jich je hemodynamicky nev\u00fdznamn\u00fdch, proto\u017ee patologick\u00e1 tk\u00e1\u0148 klade prot\u00e9kaj\u00edc\u00ed krvi velk\u00fd odpor. M\u016f\u017eeme se s nimi setkat v jak\u00e9mkoliv org\u00e1nu, nej\u010dast\u011bji v k\u016f\u017ei.<\/li>\n<li>Arterioven\u00f3zn\u00ed malformace se chovaj\u00ed agresivn\u011b.Maj\u00ed tendenci k progresivn\u00edmu a destruktivn\u00edmu\u00a0r\u016fstu. Okoln\u00ed tk\u00e1n\u011b jednak komprimuj\u00ed a eroduj\u00ed,\u00a0jednak na nich p\u016fsob\u00ed hemodynamicky (potenci\u00e1ln\u00ed arteri\u00e1ln\u00ed steel fenom\u00e9n). Perifern\u00ed tk\u00e1n\u011b mohou b\u00fdt posti\u017eeny ischemi\u00ed, kter\u00e1 m\u016f\u017ee vy\u00fastit a\u017e\u00a0do gangr\u00e9ny, nebo venostatickou dermatitidou \u010di\u00a0v\u0159edy p\u0159i \u017eiln\u00ed hypertenzi. <b>Klinicky <\/b>se tento typ\u00a0malformac\u00ed ohla\u0161uje bolestmi nebo krv\u00e1cen\u00edm\u00a0u adolescent\u016f a u mlad\u00fdch dosp\u011bl\u00fdch jedinc\u016f. Arterioven\u00f3zn\u00ed spojky zvy\u0161uj\u00edc\u00ed srde\u010dn\u00ed v\u00fddej mohou<br \/>\nv\u00e9st a\u017e k srde\u010dn\u00edmu selh\u00e1n\u00ed (obr. 13\u201316).<\/li>\n<li>Diagn\u00f3zu lze ud\u011blat pouze na z\u00e1klad\u011b klinick\u00e9ho vy\u0161et\u0159en\u00ed, ale zobrazovac\u00ed metody n\u00e1m umo\u017e\u0148uj\u00ed up\u0159esnit n\u00e1lez a prov\u00e9st diferenci\u00e1ln\u00ed diagn\u00f3zu. M\u00e1me k dispozici neinvazivn\u00ed, miniinvazivn\u00ed\u00a0(duplexn\u00ed sonografie, plicn\u00ed perfuzn\u00ed scan, MR<br \/>\nangiografii, CT angiografii) a invazivn\u00ed (selektivn\u00ed a superselektivn\u00ed arteriografie, p\u0159\u00edm\u00e1 punk\u010dn\u00ed\u00a0arteriografie, standardn\u00ed nebo p\u0159\u00edm\u00e1 punk\u010dn\u00ed flebografie) vy\u0161et\u0159ovac\u00ed metody.<\/li>\n<li>L\u00e9\u010dba arterioven\u00f3zn\u00edch malformac\u00ed je obt\u00ed\u017en\u00e1.\u010casto jsou nutn\u00e9 opakovan\u00e9 terapeutick\u00e9 z\u00e1sahy,\u00a0kombinuj\u00edc\u00ed chirurgick\u00e9 a radiointerven\u010dn\u00ed techniky. Pokud je arterioven\u00f3zn\u00ed zkrat schopn\u00fd vyvolat\u00a0srde\u010dn\u00ed selh\u00e1n\u00ed, je nutn\u00fd urgentn\u00ed l\u00e9\u010debn\u00fd z\u00e1sah\u00a0spolu se v\u010dasnou l\u00e9\u010dbou malformace. V dal\u0161\u00edch p\u0159\u00edpadech by m\u011bla b\u00fdt l\u00e9\u010dba c\u00edlen\u00e1 na pr\u016fvodn\u00ed symptomy, subjektivn\u00ed pot\u00ed\u017ee a hroz\u00edc\u00ed komplikace spojen\u00e9 s onemocn\u011bn\u00edm, jako jsou krv\u00e1cen\u00ed, ulcerace,\u00a0tk\u00e1\u0148ov\u00e1 ischemie a gangr\u00e9na nebo zv\u00fd\u0161en\u00fd srde\u010dn\u00ed\u00a0v\u00fddej. L\u00e9\u010dba je spojen\u00e1 s velk\u00fdm procentem recidiv.<br \/>\nPo nedostate\u010dn\u00e9 l\u00e9\u010db\u011b se m\u016f\u017ee malformace objevit\u00a0je\u0161t\u011b ve v\u011bt\u0161\u00edm rozsahu ne\u017e p\u0159ed l\u00e9\u010dbou. Terapie\u00a0mus\u00ed z\u00e1konit\u011b vych\u00e1zet z angiografick\u00e9ho typu l\u00e9ze.<br \/>\nV sou\u010dasn\u00e9 dob\u011b se prosazj\u00ed t\u0159i p\u0159\u00edstupy. Embolo-skleroterapie u chirurgicky ne\u0159e\u0161iteln\u00fdch l\u00e9z\u00ed.<br \/>\nChirurgick\u00e1 resekce cel\u00e9ho lo\u017eiska nebo alespo\u0148\u00a0v\u00fdkon, kter\u00fd by eliminoval hemodynamick\u00fd vliv\u00a0malformace. U velk\u00fdch, difuzn\u00edch arterioven\u00f3zn\u00edch\u00a0malformac\u00ed lze s \u00fasp\u011bchem kombinovat embolo-skleroterapii a chirurgick\u00fd v\u00fdkon.<\/li>\n<\/ul>\n<h6>KOMBINOVAN\u00c9 C\u00c9VN\u00cd DEFEKTY = HEMOLYMFATICK\u00c9 MALFORMACE<\/h6>\n<ul>\n<li><strong>Klippel\u016fv-Trenaunay\u016fv syndrom<br \/>\n<\/strong>Klippel\u016fv-Trenaunay\u016fv syndrom (KTS) je vz\u00e1cn\u00e1\u00a0sporadick\u00e1 vrozen\u00e1 c\u00e9vn\u00ed malformace <b>charakte<\/b>rizovan\u00e1 tri\u00e1dou: 1. ko\u017en\u00ed kapil\u00e1rn\u00ed malforma ce barvy portsk\u00e9ho v\u00edna, 2. atypick\u00e9 (later\u00e1ln\u00ed)\u00a0varixy a\/nebo \u017eiln\u00ed malformace a 3. hypertrofie\u00a0kost\u00ed a\/nebo m\u011bkk\u00fdch tk\u00e1n\u00ed. Jedn\u00e1 se o komplexn\u00ed kombinovanou c\u00e9vn\u00ed malformaci s pomal\u00fdm pr\u016ftokem postihuj\u00edc\u00ed kapil\u00e1ry, \u017e\u00edly a lymfatick\u00e9 c\u00e9vy.<br \/>\nNa syndrom poprv\u00e9 upozornili Francouzi Klippel a Trenaunay v roce 1900. V roce 1918 Weber popsal tento syndrom spojen\u00fd s v\u00fdskytem arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble. Jedn\u00e1 se o onemocn\u011bn\u00ed vrozen\u00e9. Famili\u00e1rn\u00ed v\u00fdskyt zat\u00edm nebyl potvrzen\u00fd, i kdy\u017e je pops\u00e1n n\u00e1lez syndromu u v\u00edce \u010dlen\u016f jedn\u00e9 rodiny. Za p\u0159\u00ed\u010dinu je pova\u017eov\u00e1na genov\u00e1 mutace nebo mezoderm\u00e1ln\u00ed abnormalita ve fet\u00e1ln\u00edm obdob\u00ed (Tian, 2004). V 95% postihuje KTS doln\u00ed kon\u010detinu, v 5% horn\u00ed kon\u010detinu a ojedin\u011ble trup. U pacient\u016f s KTS bylo pozorov\u00e1no vy\u0161\u0161\u00ed riziko plicn\u00ed embolie, kter\u00e9 je t\u00edm v\u011bt\u0161\u00ed, \u010d\u00edm rozs\u00e1hlej\u0161\u00ed jsou c\u00e9vn\u00ed malformace.<br \/>\n<b>Klinicky <\/b>nach\u00e1z\u00edme zv\u011bt\u0161en\u00ed posti\u017een\u00e9 kon\u010detiny s \u010dasto atypicky lokalizovan\u00fdmi varixy (later\u00e1ln\u00ed strana stehna) a ko\u017en\u00ed kapil\u00e1rn\u00ed malformace. Charakteristick\u00e9 je asymetrick\u00e9 posti\u017een\u00ed jen jedn\u00e9 kon\u010detiny. Pacienti si v\u011bt\u0161inou st\u011b\u017euj\u00ed na symptomy \u017eiln\u00ed insuficience, jako je otok a bolesti, zejm\u00e9na na konci dne a po z\u00e1t\u011b\u017ei. Velmi \u010dast\u00fdm steskem nemocn\u00fdch s KTS jsou bolesti v posti\u017een\u00e9 kon\u010detin\u011b, kter\u00e9 mohou m\u00edt hned n\u011bkolik r\u016fzn\u00fdch p\u0159\u00ed\u010din:\u00a01) chronick\u00e1 \u017eiln\u00ed insuficience, 2) celulitida, 3) povrchov\u00e1 tromboflebitida, 4) hlubok\u00e1 \u017eiln\u00ed tromb\u00f3za, 5) kalcifikace \u017eiln\u00edch malformac\u00ed, 6) r\u016fstov\u00e9 bolesti u d\u011bt\u00ed a dosp\u00edvaj\u00edc\u00edch, 7) intraose\u00e1ln\u00ed c\u00e9vn\u00ed malformace, 8) artritida, 9) neuropatick\u00e9 bolesti. P\u0159i ultrazvukov\u00e9m vy\u0161et\u0159en\u00ed se b\u011b\u017en\u011b setk\u00e1v\u00e1me s v\u00fdvojov\u00fdmi anom\u00e1liemi povrchov\u00fdch \u017eiln\u00edch kmen\u016f (aplazie, hypoplazie) (Herman, 2010). Diagnostick\u00fdm standardem je duplexn\u00ed sonografie, flebografie a magnetick\u00e1 rezonan\u010dn\u00ed venografie. Rozsah vy\u0161et\u0159en\u00ed by se m\u011bl odv\u00edjet od pl\u00e1novan\u00e9 l\u00e9\u010dby.<br \/>\n<b>Diferenci\u00e1ln\u011b diagnosticky <\/b>je nutn\u00e9 odli\u0161it Klippel\u016fv-Trenaunay\u016fv-Weber\u016fv syndrom, proto\u017ee terapie a progn\u00f3za t\u011bchto dvou velmi p\u0159\u00edbuzn\u00fdch onemocn\u011bn\u00ed je rozd\u00edln\u00e1. Nejl\u00e9pe se zde osv\u011bd\u010duje MR angiografie v tenk\u00fdch \u0159ezech.L\u00e9\u010dba pacient\u016f s KTS je prim\u00e1rn\u011b konzervativn\u00ed. Pou\u017e\u00edv\u00e1me p\u0159i n\u00ed kompresivn\u00ed band\u00e1\u017e nebo kompresivn\u00ed pun\u010dochu, elevaci kon\u010detiny a venofarmaka. Laserem lze o\u0161et\u0159it kapil\u00e1rn\u00ed malformace. Indikac\u00ed k operaci m\u016f\u017ee b\u00fdt rozd\u00edln\u00e1 d\u00e9lka kon\u010detin anebo varixy \u010di \u017eiln\u00ed malformace s p\u0159\u00edznaky chronick\u00e9 \u017eiln\u00ed insuficience. P\u0159ed operac\u00ed na \u017eiln\u00edm syst\u00e9mu je d\u016fle\u017eit\u00e9 jeho d\u016fkladn\u00e9 p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed, flebografi\u00ed nebo MR venografi\u00ed. P\u0159ed chirurgick\u00fdm z\u00e1sahem mus\u00ed zobrazovac\u00ed metody objasnit \u017eiln\u00ed anatomii a stav hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu. Chirurgick\u00e1 l\u00e9\u010dba se zam\u011b\u0159uje na odstran\u011bn\u00ed varix\u016f a \u017eiln\u00edch malformac\u00ed, n\u011bkdy se prov\u00e1d\u00ed rekonstrukce abnorm\u00e1ln\u00edch\u00a0hlubok\u00fdch \u017eil. K odstran\u011bn\u00ed varix\u016f a \u017eiln\u00edch malformac\u00ed se pou\u017e\u00edv\u00e1 skleroterapie alkoholem nebo p\u011bnou, endovaskul\u00e1rn\u00ed laserov\u00e1 \u010di radiofrekven\u010dn\u00ed ablace, chirurgick\u00fd striping a flebotomie. Recidiva je zde \u010dast\u00e1, ale poopera\u010dn\u00ed zlep\u0161en\u00ed subjektivn\u00edch pot\u00ed\u017e\u00ed je v\u011bt\u0161inou v\u00fdrazn\u00e9. Krom\u011b toho lze v\u017edy prov\u00e9st reoperaci, pokud je nutn\u00e1. Proto\u017ee je KTS vz\u00e1cn\u00e9 onemocn\u011bn\u00ed, p\u00e9\u010de o pacienty by m\u011bla b\u00fdt soust\u0159ed\u011bn\u00e1 do specializovan\u00fdch center.<\/li>\n<\/ul>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #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_378.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 13 AV malformace dorza nohy\" alt=\"Obr. 13 AV malformace dorza nohy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_378.jpg\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 13<br \/>AV malformace dorza nohy<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #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_379.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 14 \u010cetn\u00e9 AV malformace krku\" alt=\"Obr. 14 \u010cetn\u00e9 AV malformace krku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_379.jpg\" width=\"200\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 14<br \/>\u010cetn\u00e9 AV malformace krku<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<div id=\"attachment_3280\" style=\"width: 160px\" class=\"wp-caption alignnone\"><a style=\"color: #ff4b33; line-height: 20px; font-size: 12.222222328186035px; font-style: normal; font-weight: bold; text-align: center; background-color: #f1f1f1;\" href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_381.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3280\" class=\" wp-image-3280\" style=\"border-style: none; margin: 5px; padding: 0px; -webkit-user-drag: none;\" title=\"Obr. 15 AV malformace prstu ruky\" alt=\"Obr. 15 AV malformace prstu ruky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_381.jpg\" width=\"150\" height=\"137\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_381.jpg 306w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_381-300x274.jpg 300w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a><p id=\"caption-attachment-3280\" class=\"wp-caption-text\">Obr. 15<br \/>AV malformace prstu ruky<\/p><\/div>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 16 \u017diln\u00ed malformace prstu ruky v MR obraze\" alt=\"Obr. 16 \u017diln\u00ed malformace prstu ruky v MR obraze\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_380.gif\" width=\"200\" height=\"183\" \/><p class=\"wp-caption-text\">Obr. 16<br \/>\u017diln\u00ed malformace prstu ruky v MR obraze<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"CSSTableGenerator\">\n<tbody>\n<tr>\n<td>Tabulka \u010d. 8<br \/>\nKrit\u00e9ria pro diagnostiku Oslerova-Weberova-Renduova syndromu (podle Scientific dvisory Board\u00a0of O-W-R \u2013 HHT Foundation International, 1999)<\/td>\n<\/tr>\n<tr>\n<td>\n<ol>\n<li><strong>epistaxe<\/strong> \u2013 spont\u00e1nn\u00ed a recidivuj\u00edc\u00ed<\/li>\n<li><strong>teleangiektazie<\/strong> \u2013 mnoho\u010detn\u00e9, na charakteristick\u00fdch m\u00edstech (rty, dutina \u00fastn\u00ed, nos, prsty)<\/li>\n<li><strong>viscer\u00e1ln\u00ed posti\u017een\u00ed<\/strong> \u2013 nap\u0159. teleangiektazie v tr\u00e1v\u00edc\u00edm traktu, plicn\u00ed AV malformace, mozkov\u00e9 a m\u00ed\u0161n\u00ed AV\u00a0malformace, jatern\u00ed AV malformace<\/li>\n<li><strong>pozitivn\u00ed rodinn\u00e1 anamn\u00e9za<\/strong> \u2013 prvostup\u0148ov\u00fd p\u0159\u00edbuzn\u00fd s heredit\u00e1rn\u00ed teleangiektazi\u00ed, diagnostikovan\u00fd\u00a0podle t\u011bchto krit\u00e9ri\u00ed<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table border=\"0\" class=\"CSSTableGenerator\" width=100%>\n<tbody>\n<tr>\n<td>Tabulka \u010d. 9<br \/>\nDiferenci\u00e1ln\u00ed diagnostika Oslerova-Weberova-Renduova syndromu<\/td>\n<\/tr>\n<tr>\n<td>\n<ol>\n<li><strong>Esenci\u00e1ln\u00ed teleangiektazie<\/strong><\/li>\n<li><strong>Ataxie-teleangiektazie\u00a0<\/strong>\u2013 vrozen\u00e1 prim\u00e1rn\u00ed kombinovan\u00e1 imunodeficience manifestuj\u00edc\u00ed se kolem 11. m\u011bs\u00edce\u00a0\u017eivota komplexn\u00edm syndromem (imunodeficit, ataxie, teleangiektazie)<\/li>\n<li><strong>CREST syndrom<\/strong> (Calcinosis, Raynaud\u016fv syndrom, Esofage\u00e1ln\u00ed dysmotilita, Sklerodaktylie, Teleangiektazie)\u00a0\u2013 limitovan\u00e1 forma sklerodermie<\/li>\n<li><strong>Rosacea (acne rosacea, r\u016f\u017eovka)<\/strong> \u2013 z\u00e1n\u011btliv\u00e9 onemocn\u011bn\u00ed k\u016f\u017ee obli\u010deje, nej\u010dast\u011bji ve st\u0159edn\u00edm v\u011bku, projevuj\u00edc\u00ed\u00a0se z\u010derven\u00e1n\u00edm nosu a tv\u00e1\u0159\u00ed (roz\u0161\u00ed\u0159en\u00e9 \u017eilky a na\u010dervenal\u00e9 pup\u00ednky), n\u011bkdy z\u00e1n\u011bty o\u010d\u00ed a zv\u011bt\u0161en\u00edm\u00a0\u010derven\u00e9ho nosu (rinofyma)<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<ul>\n<li><strong>Klippel\u016fv-Trenaunay\u016fv-Weber\u016fv syndrom<br \/>\n<\/strong>Klinick\u00fd obraz je obdobn\u00fd jako u Klippelova-Trenaunayova syndromu, ale tato kombinovan\u00e1 c\u00e9vn\u00ed malformace pat\u0159\u00ed mezi vysoko pr\u016ftokov\u00e9, proto\u017ee do jej\u00edho obrazu n\u00e1le\u017e\u00ed hemodynamicky v\u00fdznamn\u00e9 arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011ble. Ve srovn\u00e1n\u00ed s Klippelov\u00fdm-Trenaunayov\u00fdm syndromem zde p\u0159i klinick\u00e9m vy\u0161et\u0159en\u00ed nach\u00e1z\u00edme difuzn\u011bj\u0161\u00ed kapil\u00e1rn\u00ed malformace. \u010cast\u011bji se zde tak\u00e9 objevuj\u00ed defekty k\u016f\u017ee\u00a0a podko\u017e\u00ed a v n\u011bkter\u00fdch p\u0159\u00edpadech doch\u00e1z\u00ed v d\u016fsledku velk\u00fdch arterioven\u00f3zn\u00edch zkrat\u016f k srde\u010dn\u00edmu selh\u00e1n\u00ed. Terapeutick\u00fd p\u0159\u00edstup je stejn\u00fd jako u arterioven\u00f3zn\u00edch malformac\u00ed. Efektivn\u00ed l\u00e9\u010dbou je transarteri\u00e1ln\u00ed embolizace.<\/li>\n<li><strong>Maffucciho syndrom<br \/>\n<\/strong>Jde o vz\u00e1cnou vrozenou poruchu mezenchymov\u00e9\u00a0tk\u00e1n\u011b. Onemocn\u011bn\u00ed je charakterizovan\u00e9 difuzn\u00ed\u00a0asymetrickou chondrodystrofi\u00ed, enchondromy\u00a0(benign\u00ed n\u00e1dory chrupavky) a deformitami skeletu, kter\u00e9 se r\u016fstem zv\u011bt\u0161uj\u00ed, a tmav\u011b \u010derven\u00fdmi\u00a0hemangiomy nepravideln\u00e9ho tvaru (mate\u0159sk\u00e1 pigmentov\u00e1 znam\u00e9nka). Na k\u016f\u017ei a vnit\u0159n\u00edch org\u00e1nech\u00a0jsou \u010detn\u00e9 angiomy a vitiligo. Jsou \u010dast\u00e9 fraktury.<\/li>\n<li><strong>Bean\u016fv syndrom (blue rubber bleb naevus syndrome)<br \/>\n<\/strong>Jedn\u00e1 se o autozom\u00e1ln\u011b dominantn\u011b d\u011bdi\u010dnou\u00a0\u017eiln\u00ed malformaci charakterizovanou stla\u010diteln\u00fdmi<i>\u00a0m<\/i>odr\u00fdmi podko\u017en\u00edmi ven\u00f3zn\u00edmi uzly. Jejich po\u010det a velikost v\u00fdrazn\u011b kol\u00edsaj\u00ed. \u017diln\u00ed malformace vznikaj\u00ed tak\u00e9 v gastrointestin\u00e1ln\u00edm traktu. Zde mohou b\u00fdt klinicky zcela asymptomatick\u00e9. N\u011bkdy vyvol\u00e1vaj\u00ed chronick\u00e9 okultn\u00ed krv\u00e1cen\u00ed do tr\u00e1vic\u00edho traktu s pomalou anemizac\u00ed nebo m\u016f\u017eou b\u00fdt p\u0159\u00ed\u010dinou bolest\u00ed b\u0159icha prov\u00e1zen\u00fdch v\u00fdznamn\u00fdm krv\u00e1cen\u00edm s rychlou anemizac\u00ed.<\/li>\n<li><strong>Sturge\u016fv-Weber\u016fv-Krabbe\u016fv syndrom (neuroangiomatosis encephalofacialis, angioma capillare et venosum calcificans)<br \/>\n<\/strong>Syndrom je charakterizov\u00e1n \u017eiln\u00edmi a kapil\u00e1rn\u00edmi malformacemi distribuovan\u00fdmi v oblasti prvn\u00ed v\u011btve trigeminu, mozku (ipsilater\u00e1ln\u00ed angiomat\u00f3za m\u011bkk\u00fdch plen mozkov\u00fdch, tedy <i>pia mater <\/i>a <i>arachnoidey<\/i>, bohat\u00fdch c\u00e9vami) a oka (c\u00e9vn\u00ed malformace <i>choroidey <\/i>\u2013 c\u00e9vnatky). Tato autozom\u00e1ln\u011b dominantn\u011b d\u011bdi\u010dn\u00e1 angiomat\u00f3za vede k poruch\u00e1m v\u00fdvoje mozku (roz\u0161\u00ed\u0159en\u00ed mozkov\u00fdch komor), k epileptiformn\u00edm k\u0159e\u010d\u00edm, spastick\u00fdm par\u00e9z\u00e1m, k oligofrenii a glaukomu. V obli\u010deji vznik\u00e1 oby\u010dejn\u011b jednostrann\u00fd <i>naevus flammeus <\/i>(typ kapil\u00e1rn\u00ed malformace) v oblasti prvn\u00ed v\u011btve trigeminu.<\/li>\n<li><strong>Osler\u016fv-Weber\u016fv-Rendu\u016fv syndrom (heredit\u00e1rn\u00ed hemoragick\u00e1 teleangiektazie)<br \/>\n<\/strong>Autozom\u00e1ln\u011b dominantn\u011b d\u011bdi\u010dn\u00e9 onemocn\u011bn\u00ed spojen\u00e9 s <b>teleangiektaziemi a arterioven\u00f3zn\u00edmi malformacemi<\/b>, kter\u00e9 se nej\u010dast\u011bji klinicky projevuje opakovan\u00fdmi epistaxemi. Z\u00e1va\u017en\u011bj\u0161\u00ed krv\u00e1cen\u00ed do mozku, plic a tr\u00e1vic\u00edho traktu p\u0159i v\u011bt\u0161\u00edch teleangiektazi\u00edch a AV malformac\u00edch jsou podstatn\u011b vz\u00e1cn\u011bj\u0161\u00ed. M\u016f\u017ee se manifestovat ji\u017e v d\u011btstv\u00ed, ale v\u011bt\u0161inou se projev\u00ed v adolescenci nebo v mlad\u0161\u00edm dosp\u011bl\u00e9m v\u011bku do 30 let.Diagnostika se tradi\u010dn\u011b op\u00edr\u00e1 o klasickou tri\u00e1du: epistaxe, teleangiektazie a pozitivn\u00ed rodinn\u00e1 anamn\u00e9za (tab. 8). Diagn\u00f3za heredit\u00e1rn\u00ed teleangiektazie je potvrzen\u00e1, pokud jsou spln\u011bna 3 ze\u00a04 diagnostick\u00fdch krit\u00e9ri\u00ed. Pokud nach\u00e1z\u00edme pouze\u00a02 z t\u011bchto krit\u00e9ri\u00ed, je diagn\u00f3za <b>pravd\u011bpodobn\u00e1<\/b>.<br \/>\nK potvrzen\u00ed diagn\u00f3zy se n\u011bkdy prov\u00e1d\u00ed ko\u017en\u00ed biopsie. Histopatologick\u00fd n\u00e1lez prok\u00e1\u017ee dilatovan\u00e9 kapil\u00e1ry a c\u00e9vn\u00ed novotvorbu v horizont\u00e1ln\u00edm suprapapil\u00e1rn\u00edm c\u00e9vn\u00edm plexu.<br \/>\nEpistaxe postihuje asi 95% nemocn\u00fdch. Teleangiektazie se objevuj\u00ed nej\u010dast\u011bji v pubert\u011b. T\u00e9m\u011b\u0159 v\u017edy postihuj\u00ed rty a \u00fastn\u00ed sliznici. Dal\u0161\u00edm typick\u00fdm m\u00edstem jejich v\u00fdsevu jsou tv\u00e1\u0159e, nos, u\u0161i, trup a prsty na rukou. Charakteristick\u00fdm, ale ne patognomonick\u00fdm n\u00e1lezem jsou teleangiektazie nehtov\u00fdch l\u016f\u017eek. Teleangiektazie na sliznici tr\u00e1vic\u00edho traktu b\u00fdvaj\u00ed p\u0159\u00ed\u010dinou sideropenick\u00e9 an\u00e9mie a mel\u00e9ny.<\/li>\n<\/ul>\n<h6>Z\u00e1va\u017en\u00e9 klinick\u00e9 projevy:<\/h6>\n<ol>\n<li>rozs\u00e1hl\u00e9 plicn\u00ed AV malformace \u2013 pravo-lev\u00fd zkrat\u00a0s hypoxemi\u00ed a cyan\u00f3zou,<\/li>\n<li>AV malformace mozku a m\u00edchy \u2013 c\u00e9vn\u00ed mozkov\u00e9\u00a0p\u0159\u00edhody, lo\u017eiskov\u00e9 neurologick\u00e9 projevy,<\/li>\n<li>rozs\u00e1hl\u00e9 posti\u017een\u00ed jater teleangiektaziemi \u2013 hepatomegalie, port\u00e1ln\u00ed hypertenze, cirh\u00f3za.<\/li>\n<\/ol>\n<p>Pokud se najde a kontroluje zdroj krv\u00e1cen\u00ed, je progn\u00f3za dobr\u00e1. Opakovan\u00e1 krv\u00e1cen\u00ed z nosu nebo do tr\u00e1vic\u00edho traktu vedou k sideropenick\u00e9 an\u00e9mii. Epistaxe se mohou s v\u011bkem zhor\u0161ovat, u 10\u201330% pacient\u016f si vy\u017e\u00e1daj\u00ed krevn\u00ed transfuze. Plicn\u00ed AV malformace<br \/>\na rozs\u00e1hl\u00e9 teleangiektazie tr\u00e1vic\u00edho traktu mohou vyvolat \u017eivot ohro\u017euj\u00edc\u00ed krv\u00e1cen\u00ed.<\/p>\n<p>Terapie je v\u011bt\u0161inou symptomatick\u00e1 a podp\u016frn\u00e1. Omezuje se na lok\u00e1ln\u00ed l\u00e9\u010dbu epistaxe (tampon\u00e1dy, kauterizace, sept\u00e1ln\u00ed dermoplastika u t\u011b\u017ek\u00fdch a opakovan\u00fdch epistax\u00ed), krevn\u00ed transfuze a pod\u00e1v\u00e1n\u00ed prepar\u00e1t\u016f \u017eeleza. Kyselina aminokapronov\u00e1 a jin\u00e1 antifibrinolytika se pou\u017e\u00edvaj\u00ed v prevenci a l\u00e9\u010db\u011b slizni\u010dn\u00edch krv\u00e1cen\u00ed. Peror\u00e1ln\u00ed hormon\u00e1ln\u00ed antikoncepce pom\u00e1h\u00e1 l\u00e9\u010dit chronick\u00e1, skryt\u00e1 krv\u00e1cen\u00ed do tr\u00e1vic\u00edho traktu. V l\u00e9\u010db\u011b se tak\u00e9 pou\u017e\u00edv\u00e1 elektrokauterizace a laserov\u00e1 ablace ko\u017en\u00edch a slizni\u010dn\u00edch teleangiektazi\u00ed. U nemocn\u00fdch s oboustrann\u00fdm posti\u017een\u00edm plic je \u00fa\u010dinnou l\u00e9\u010dbou translumin\u00e1ln\u00ed embolizace plicn\u00edch p\u00ed\u0161t\u011bl\u00ed. Solit\u00e1rn\u00ed l\u00e9ze, stejn\u011b jako symptomatick\u00e9 l\u00e9ze p\u0159i difuzn\u00edm posti\u017een\u00ed, mohou b\u00fdt \u0159e\u0161eny chirurgicky. Jedn\u00e1 se o d\u011bdi\u010dn\u00e9 onemocn\u011bn\u00ed, a proto je nutn\u00e9 tak\u00e9 vy\u0161et\u0159en\u00ed rodinn\u00fdch p\u0159\u00edslu\u0161n\u00edk\u016f a objasn\u011bn\u00ed genetick\u00e9ho zp\u016fsobu p\u0159enosu vloh pro vznik t\u00e9to vrozen\u00e9 poruchy.<br \/>\n<!--nextpage--><\/p>\n<h3>Literatura<\/h3>\n<h4>Ke kapitol\u00e1m 1\u20132, 4\u20139<\/h4>\n<ul>\n<li>RUTHERFORD, R. B. (CRONENWET T J. L. , JOHNSTON K. W. ). Vascular Surgery. 7th Edition 2010. Saunders Elsevier 2010.<\/li>\n<li>FIRT, P. , HEJNAL, J. , VAN\u011aK, I. C\u00e9vn\u00ed chirurgie. Nakladatelstv\u00ed Karolinum 2006.<\/li>\n<li>LUMLEY J. S. P. , HOBALLAH J. J. Vascular Surgery. SpringerVerlag Berlin Heidelberg 2009.<\/li>\n<li>HEBERER, G. , VAN DONGEN R. J. A. M. Gef\u00e4sschirurgie. SpringerVerlag Berlin HeidelbergNew York 1987.<\/li>\n<li>GLOWITZKI P. Handbook of Venous Disorders. 3rd Edition. Hodder Arnold 2009.<\/li>\n<li>BERGAN, J. J. The Vein Book. Elsevier Academic Press Inc 2007.<\/li>\n<\/ul>\n<p>Ke kapitole 3<\/p>\n<ul>\n<li>KRAJ\u00cd\u010cEK M. , PEREGRIN, J. H. , RO\u010cEK, M. , \u0160EBESTA, P. , a kol. Chirurgick\u00e1 a interven\u010dn\u00ed l\u00e9\u010dba c\u00e9vn\u00edch onemocn\u011bn\u00ed. Grada Publishing, a. s. , 2007. ISBN 9788024706078.<\/li>\n<\/ul>\n<h4>Ke kapitole 10<\/h4>\n<ul>\n<li>BATES, S. M. TREATMENT OF DEEP VENOUS THROMBOSIS. N ENGL J MED 2004; 351: S. 452\u2013463.<\/li>\n<li>BERGAN, J. J. The Vein Book. Elsevier Academic Press Inc 2007.<\/li>\n<li>BROUL\u00cdKOV\u00c1, A. Antikoagula\u010dn\u00ed l\u00e9\u010dba \u017eiln\u00ed tromb\u00f3zy. s. 41\u201345. In: Eli\u0161ka, O. , Sp\u00e1\u010dil, J. , \u0160tvrtinov\u00e1, V. <i>Angiologie 2008. Trendy soudob\u00e9 angio<\/i>logie. Gal\u00e9n 2008, 130 s.<\/li>\n<li>ETHUNANDAN, M. , MELLOR, T. K. Hemangiomas and vascular malformations of the maxillofacial region \u2013 a review. <i>Br J Oral Maxillofac <\/i>Surg 2006; 44: s. 263\u2013272.<\/li>\n<li>FIRT, P. , HEJNAL, J. , VAN\u011aK, I. C\u00e9vn\u00ed chirurgie. Nakladatelstv\u00ed Karolinum 2006.<\/li>\n<li>GLOWITZKI. P. Handbook of Venous Disorders. 3rd Edition. Hodder Arnold 2009.<\/li>\n<li>HEBERER, G. , van DONGEN, R. J. A. M. Gef\u00e4sschirurgie. SpringerVerlag Berlin HeidelbergNew York 1987.<\/li>\n<li>HERMAN, J. , LO VECEK , M. , D U DA , M. ,<\/li>\n<li>SVACH, I. A rare complication of varicose veinsurgery. <i>Phlebology<\/i>, 15, 2000, p. 43\u201345.<\/li>\n<li>HERMAN, J. , DUDA, M. Chronick\u00e1 ven\u00f3zn\u00ed insuficience pohledem miniinvazivn\u00edho chirurga. <i>Prakt <\/i>Flebol, 1999; 8: s. 49\u201360.<\/li>\n<li>KAHN, S. R. Relationship between deep venous thrombosis and the postthrombotic syndrome. <i>Arch Int Med <\/i>2004; 164: s. 17\u201326.<\/li>\n<li>KALETOV\u00c1, M. , MUSIL, D. Akutn\u00ed stavy ve flebologii. <i>Intern\u00ed Med <\/i>2006, 9: s. 380\u2013384.<\/li>\n<li>HERMAN, J. , MUSIL, D. KlippelTrenaunay syndrome associated with great saphenous vein aplasia. <i>Phlebology <\/i>2010; 1: s. 35\u201337.<\/li>\n<li>LEE, B. B. , LAREDO, J. , LEE, T. S. , HUH, S. ,<\/li>\n<li>NEVILLE, R. Terminolog y and classificationof congenital vascular malformations. <i>Phlebo<\/i>logy 2007; 22: s. 249\u2013252.<\/li>\n<li>LEE, B. B. , BERGAN, J. , GLOVICZKI, P. , et al: Diagnosis and treatment of venous malformationsConsensus Document of the International Unionof Phlebology (IUP)2009. <i>Int Angiol <\/i>2009; 28:s. 434\u2013451.<\/li>\n<li>LUMLEY, J. S. P. , Hoballah, J. J. Vascular Surgery. SpringerVerlag Berlin Heidelberg 2009.<\/li>\n<li>MARIK, P. E. , PLANTE, L. A. Venous thromboembolic disease and pregnancy. <i>N Engl J Med <\/i>2008;359: s. 2025\u20132031.<\/li>\n<li>MULLIKEN, J. B. , GLOWACKI, J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. <i>Plast Reconstr Surg <\/i>1982; 69: s. 412\u2013422.<\/li>\n<li>MUSIL, D. Rizika a prevence tromboembolick\u00e9 choroby. <i>Med. Pro Praxi <\/i>2009; 6 (2): s. 61\u201365.<\/li>\n<li>RUTHERFORD, R. B. (Cronenwett, J. L. , Johnston, K. W. ). Vascular Surgery. 7th Edition 2010. Saunders Elsevier 2010.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>TERMINOLOGIE Chronick\u00e1 \u017eiln\u00ed porucha \u2013 term\u00edn ozna\u010duje cel\u00e9 spektrum morfologick\u00fdch a funk\u010dn\u00edch abnormalit \u017eiln\u00edho syst\u00e9mu (asymptomatick\u00fdch\/symptomatick\u00fdch, l\u00e9\u010den\u00fdch\/nel\u00e9\u010den\u00fdch). Chronick\u00e9 \u017eiln\u00ed onemocn\u011bn\u00ed \u2013 jak\u00e1koliv dlouhotrvaj\u00edc\u00ed morfologick\u00e1 a funk\u010dn\u00ed abnormalita \u017eiln\u00edho syst\u00e9mu projevuj\u00edc\u00ed se symptomy a\/nebo zn\u00e1mkami (viditeln\u00fdmi projevy), kter\u00e1 vy\u017eaduje vy\u0161et\u0159en\u00ed a\/nebo l\u00e9\u010dbu. Varixy (C1\u2013C2) \u2013 lehk\u00e1 forma chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed, venektazie, retikul\u00e1rn\u00ed a uzlovit\u00e9 varixy. Chronick\u00e1 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":50,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2322","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2322","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=2322"}],"version-history":[{"count":50,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2322\/revisions"}],"predecessor-version":[{"id":2402,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2322\/revisions\/2402"}],"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=2322"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}