{"id":2958,"date":"2013-05-21T09:56:15","date_gmt":"2013-05-21T09:56:15","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2958"},"modified":"2013-06-08T06:53:39","modified_gmt":"2013-06-08T06:53:39","slug":"4-diagnostika-a-lecba-varixu-dolnich-koncetin-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2958","title":{"rendered":"4 Diagnostika a l\u00e9\u010dba varix\u016f doln\u00edch kon\u010detin"},"content":{"rendered":"<h6>TERMINOLOGIE<\/h6>\n<ul>\n<li style=\"text-align: justify;\">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).<\/li>\n<li style=\"text-align: justify;\">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.<\/li>\n<li style=\"text-align: justify;\">Varixy (C1\u2013C2) \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;\">Chronick\u00e1 \u017eiln\u00ed insuficience (C3\u2013C6) \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;\">PrEVAIT \u2013 zkratka znamenaj\u00edc\u00ed PREsence of Varices After In Tervention (p\u0159\u00edtomnost rezidu\u00e1ln\u00edch nebo rekurentn\u00edch varix\u016f po l\u00e9\u010db\u011b).<\/li>\n<li style=\"text-align: justify;\">rekurentn\u00ed (recidivuj\u00edc\u00ed) varixy \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;\">rezidu\u00e1ln\u00ed varixy \u2013 varixy, kter\u00e9 z\u016fstaly (byly ponech\u00e1ny) po l\u00e9\u010db\u011b (Eklof, 2009).<\/li>\n<\/ul>\n<h4>4.1 Chronick\u00e1 \u017eiln\u00ed onemocn\u011bn\u00ed\u00a0(\u017eiln\u00ed insuficience)<\/h4>\n<h6>EPIDEMIOLOGIE<\/h6>\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 je 73,4\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.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 aktivita 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.<\/p>\n<p style=\"text-align: justify;\">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=\"border-width: 0px; border-color: #ffffff; width: 100%; background-color: #ffffff;\" 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\/05\/Image_161.png\"><img decoding=\"async\" title=\"Obr. 1 \u2013 Krv\u00e1cej\u00edc\u00ed varix\" alt=\"Obr. 1 \u2013 Krv\u00e1cej\u00edc\u00ed varix\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_161.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1 \u2013 Krv\u00e1cej\u00edc\u00ed varix<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 160px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_163.png\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Varixy doln\u00edch kon\u010detin\" alt=\"Obr. 2 \u2013 Varixy doln\u00edch kon\u010detin\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_163.png\" width=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Varixy doln\u00edch kon\u010detin<\/p><\/div><\/td>\n<\/tr>\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\/05\/Image_164.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Chronick\u00e1 \u017eiln\u00ed insuficience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi zm\u011bnami k\u016f\u017ee\" alt=\"Obr. 3 \u2013 Chronick\u00e1 \u017eiln\u00ed insuficience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi zm\u011bnami k\u016f\u017ee\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_164.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3 \u2013 Chronick\u00e1 \u017eiln\u00ed insuficience ve stadiu C4 (CVI C4) s pigmentov\u00fdmi<br \/>zm\u011bnami k\u016f\u017ee<\/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\/05\/Image_165.png\"><img decoding=\"async\" title=\"Obr. 4 \u2013 B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insuficience ve stadiu C6 \u2013 CVI C6)\" alt=\"Obr. 4 \u2013 B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insuficience ve stadiu C6 \u2013 CVI C6)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_165.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4 \u2013 B\u00e9rcov\u00fd v\u0159ed \u017eiln\u00ed etiologie (chronick\u00e1 \u017eiln\u00ed insuficience<br \/>ve stadiu C6 \u2013 CVI C6)<\/p><\/div><\/td>\n<\/tr>\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\/05\/Image_166.png\"><img decoding=\"async\" title=\"Obr. 5 \u2013 B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na za\u010d\u00e1tku l\u00e9\u010dby\" alt=\"Obr. 5 \u2013 B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na za\u010d\u00e1tku l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_166.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5 \u2013 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=\"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\/05\/Image_167.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 B\u00e9rcov\u00fd v\u0159ed sm\u00ed\u0161en\u00e9 tepenn\u00e9 a \u017eiln\u00ed etiologie \u2013 na konci l\u00e9\u010dby\" alt=\"Obr. 6 \u2013 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\/05\/Image_167.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6 \u2013 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<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\u011b-svalov\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\u00a0do 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\u011b-svalov\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.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 (lymfo-ven\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).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\">\n<tbody>\n<tr>\n<td colspan=\"2\">\n<p style=\"text-align: center;\"><span style=\"color: #ffffff;\"><strong>Tabulka:<\/strong><\/span><br \/>\n<span style=\"color: #ffffff;\"><strong>Klinick\u00e9 t\u0159\u00edd\u011bn\u00ed chronick\u00e9ho \u017eiln\u00edho onemocn\u011bn\u00ed\u00a0podle CEAP klasifikace<\/strong><\/span><br \/>\n<span style=\"color: #ffffff;\"><strong>(Consensus statement, 1995)<\/strong><\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 25%;\" align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>0<\/sub><\/td>\n<td>\u2013 \u017e\u00e1dn\u00e9 viditeln\u00e9 nebo hmatn\u00e9\u00a0zn\u00e1mky \u017eiln\u00edho onemocn\u011bn\u00ed<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>1<\/sub><\/td>\n<td>\u2013 teleangiektazie nebo retikul\u00e1rn\u00ed\u00a0varixy<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>2<\/sub><\/td>\n<td>\u2013 uzlovit\u00e9 varixy<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>3<\/sub><\/td>\n<td>\u2013 otok na doln\u00ed kon\u010detin\u011b<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>4<\/sub><\/td>\n<td>\u2013 ko\u017en\u00ed zm\u011bny v d\u016fsledku \u017eiln\u00edho\u00a0onemocn\u011bn\u00ed (nap\u0159. pigmentace,\u00a0\u017eiln\u00ed ekz\u00e9m, lipodermatoskler\u00f3za)<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>5<\/sub><\/td>\n<td>\u2013 ko\u017en\u00ed zm\u011bny jak uvedeno v\u00fd\u0161e\u00a0s vyhojen\u00fdm v\u0159edem<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" valign=\"top\">T\u0159\u00edda C<sub>6<\/sub><\/td>\n<td>\u2013 ko\u017en\u00ed zm\u011bny jak uvedeno v\u00fd\u0161e\u00a0s aktivn\u00edm v\u0159edem<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">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).<\/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.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. 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.C\u00edlem l\u00e9\u010dby \u017eiln\u00ed insuficience je eliminovat nebo alespo\u0148 sn\u00ed\u017eit ambulantn\u00ed \u017eiln\u00ed hypertenzi. <b>Konzer\u00advativn\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,\u00a01996). 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;\">Venofarmaka 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).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\u00e1noprotektivn\u00ed p\u016fsoben\u00ed.<\/p>\n<p style=\"text-align: justify;\">Doba l\u00e9\u010den\u00ed venofarmaky nen\u00ed p\u0159esn\u011b stanovena. \u00davodn\u00ed pod\u00e1v\u00e1n\u00ed jak\u00e9hokoliv venofarmaka by m\u011blo trvat 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 (ultrasound-guided 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.<\/p>\n<p style=\"text-align: justify;\">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;\">\u017diln\u00ed b\u00e9rcov\u00fd v\u0159ed p\u0159edstavuje tvrd\u00fd terapeutick\u00fd o\u0159\u00ed\u0161ek. 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, p\u0159i\u010dem\u017e je d\u016fraz kladen\u00fd na lok\u00e1ln\u00ed\u00a0a kompresivn\u00ed l\u00e9\u010dbu dopln\u011bnou re\u017eimov\u00fdmi opat\u00ad\u0159en\u00edmi.<\/p>\n<p>Fyzioterapie p\u0159edstavuje intenzivn\u00ed tr\u00e9nink ch\u016fz\u00ed,\u00a0zlep\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;\">Z\u00e1kladn\u00edm kamenem l\u00e9\u010dby b\u00e9rcov\u00fdch v\u0159ed\u016f \u017eil\u00adn\u00edho p\u016fvodu je \u00fa\u010dinn\u00e1 kompresivn\u00ed terapie (tlak\u00a0nad kotn\u00edkem alespo\u0148 35 mm Hg). P\u0159ednost se d\u00e1v\u00e1\u00a0m\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;\">Lok\u00e1ln\u00ed terapie 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. <b>Syst\u00e9mov\u00e1 farmakoterapie <\/b>(aspirin, pentoxyphyllin, prostaglandiny, flavonoidy atd.) zat\u00edm sehr\u00e1v\u00e1 pouze pomocnou \u00falohu.<\/p>\n<h4>4.2 Akutn\u00ed \u017eiln\u00ed onemocn\u011bn\u00ed<\/h4>\n<h5>4.2.1 Tromboflebitida<\/h5>\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.<\/p>\n<p style=\"text-align: justify;\">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;\">Tromboflebitis vulgaris superficialis \u2013 prim\u00e1rn\u00ed povrchov\u00e1 tromboflebitida\/flebitida (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\u00a0\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>infuz\u00adn\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;\">Varikoflebitida (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;\">Tromboflebitis saltans seu migrans (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 Mondorova choroba. 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.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">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.<\/p>\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 \u00falevu od 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<h5>4.2.2 Flebotromb\u00f3za<\/h5>\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;\">Arteri\u00e1ln\u00ed tromby 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 \u017eiln\u00ed tromby 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>Ji\u017e v 19. stolet\u00ed definoval Virchow t\u0159i z\u00e1kladn\u00ed etiologick\u00e9 faktory flebotromb\u00f3zy \u2013 <strong>po\u0161kozen\u00ed c\u00e9v\u00adn\u00ed st\u011bny<\/strong>, m\u011bstn\u00e1n\u00ed krve a \u201ezm\u011bny ve slo\u017een\u00ed krve\u201c (hyperkoagulabilita \u2013 hyperkoagula\u010dn\u00ed stav).<\/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.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\u00a0uz\u00e1v\u011bru \u017eil p\u00e1nve je vhodn\u011bj\u0161\u00ed transfemor\u00e1ln\u00ed ascendentn\u00ed flebografie nebo MRI. 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).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<ul>\n<li style=\"text-align: justify;\">Terapie TEN m\u00e1 dva c\u00edle:\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<\/li>\n<\/ul>\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\u0148ujea urychluje spont\u00e1nn\u00ed (endogenn\u00ed) plazmatickoufibrinol\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 %posti\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;\">parenter\u00e1ln\u00edch heparin\u016f (nefrakcionovan\u00fd\u00a0heparin \u2013 UFH, n\u00edzkomolekul\u00e1rn\u00ed hepariny \u2013 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\u00f3zu \u2013 b\u00e9rcov\u00e9 \u017e\u00edly a svalov\u00e9 \u017e\u00edly b\u00e9rce),<\/li>\n<li style=\"text-align: justify;\">peror\u00e1ln\u00edch antagonist\u016f vitaminu K (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<br \/>\n<\/strong>Komprese vypr\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. Kompresivn\u00ed l\u00e9\u010dba tak\u00e9\u00a0p\u0159edstavuje d\u016fle\u017eitou prevenci plicn\u00ed embolie\u00a0a pozd\u011bj\u0161\u00edho rozvoje posttrombotick\u00e9ho syndro\u00admu (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 lets 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 (<i>phlegmasia cerulea\u00a0<\/i>dolens).<\/p>\n<ul>\n<li style=\"text-align: justify;\">Mobilizace pacienta \u2013 pokud v ch\u016fzi nebr\u00e1n\u00ed\u00a0otok 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\u00a0p\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.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<h5>4.2.3 Cestovn\u00ed tromb\u00f3za<\/h5>\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.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\/m2, vy\u0161\u0161\u00edch ne\u017e 190 cm a u \u017een u\u017e\u00edvaj\u00edc\u00edch hormon\u00e1ln\u00ed antikoncepci.<\/p>\n<h5>4.2.4 Phlegmasia dolens<\/h5>\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>Flegmazie se vyskytuje ve dvou klinick\u00fdch form\u00e1ch:<\/p>\n<ol>\n<li style=\"text-align: justify;\"><strong>Phlegmasia alba dolens<\/strong> \u2013 vznik\u00e1 p\u0159i rozs\u00e1hl\u00e9\u00a0tromb\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.<\/li>\n<li 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.U 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).<\/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<h5>4.2.5 Posttrombotick\u00fd syndrom<\/h5>\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 projev\u016f, flebotromb\u00f3za v anamn\u00e9ze a ultrasonografick\u00fd pr\u016fkaz \u017eiln\u00ed insuficience (chlopenn\u00ed dysfunkce) a\/nebo obstrukce.<\/p>\n<p style=\"text-align: justify;\">L\u00e9\u010debn\u00e9 mo\u017enosti jsou zde omezen\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-width: 0px; border-color: #ffffff; width: 100%; background-color: #ffffff;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 33%; border: 1px solid #ffffff; background-color: #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\/05\/Image_175.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 7 \u2013 Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed\" alt=\"Obr. 7 \u2013 Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_175.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 7 \u2013 Phlegmasia coerulea dolens p\u0159i p\u0159ijet\u00ed<\/p><\/div><\/td>\n<td style=\"width: 33%; border: 1px solid #ffffff; background-color: #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\/05\/Image_176.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 8 \u2013 Phlegmasia coerulea dolens v pr\u016fb\u011bhu l\u00e9\u010dby\" alt=\"Obr. 8 \u2013 Phlegmasia coerulea dolens v pr\u016fb\u011bhu l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_176.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 8 \u2013 Phlegmasia coerulea dolens v pr\u016fb\u011bhu<br \/>l\u00e9\u010dby<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #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\/05\/Image_177.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 9 \u2013 Phlegmasia coerulea dolens na konci l\u00e9\u010dby\" alt=\"Obr. 9 \u2013 Phlegmasia coerulea dolens na konci l\u00e9\u010dby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_177.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 9 \u2013 Phlegmasia coerulea dolens na konci l\u00e9\u010dby<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>4.3 Diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed<\/h4>\n<h5>4.3.1 Klinick\u00e1 diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed \u2013 anamn\u00e9za<\/h5>\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 vyskytnout 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.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 a \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\u00ed l\u00e9\u010dby, psychiatrick\u00fdch l\u00e9k\u016f (antipsychotika, anticholinergika).<\/li>\n<li style=\"text-align: justify;\"><strong>Pracovn\u00ed anamn\u00e9za<br \/>\n<\/strong>Je 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 sportys 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<h5>4.3.2 Klinick\u00e9 projevy \u017eiln\u00edch onemocn\u011bn\u00ed<\/h5>\n<p style=\"text-align: justify;\">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, lo\u00ad k\u00e1ln\u00ed bolestivost (spont\u00e1nn\u00ed, palpa\u010dn\u00ed nebo n\u00e1ma\u00ad hov\u00e1) a na doln\u00edch kon\u010detin\u00e1ch pocity t\u00edhy, \u00fanavy, bolesti a no\u010dn\u00ed svalov\u00e9 k\u0159e\u010de. 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;\">Fyzik\u00e1ln\u00ed (objektivn\u00ed) vy\u0161et\u0159en\u00ed kon\u010detin Nejjednodu\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;\">Pohledem zji\u0161\u0165ujeme: otok, 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;\">Pohmatem zji\u0161\u0165ujeme: teplotu 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;\">Auskultac\u00ed p\u00e1tr\u00e1me po \u0161elestech (arterio-ven\u00f3zn\u00ed p\u00ed\u0161t\u011ble, c\u00e9vn\u00ed malformace).<br \/>\nP\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;\">\u017diln\u00ed otok<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\u00e1rdo 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;\">Liped\u00e9m 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. 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. 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;\">Myxed\u00e9m 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;\">Hypertrofie podko\u017en\u00ed tk\u00e1n\u011b \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;\">Lymfed\u00e9m \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;\">Angioneurotick\u00fd ed\u00e9m (Quinckeho ed\u00e9m) \u2013 vznik\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=\"width: 50%; text-align: center;\" colspan=\"2\"><span style=\"color: #ffffff;\"><strong>Oboustrann\u00e9 otoky doln\u00edch kon\u010detin<\/strong><\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; text-align: center;\"><span style=\"color: #ffffff;\"><strong>Otok<\/strong><\/span><\/td>\n<td style=\"text-align: center;\" width=\"660\" height=\"24\"><span style=\"color: #ffffff;\"><strong>P\u0159\u00ed\u010dina<\/strong><\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Statick\u00fd (\u201efyziologick\u00fd\u201c)<\/span><\/td>\n<td height=\"24\"><span>imobilizace a vy\u0159azen\u00ed \u017eiln\u011b-svalov\u00e9 pumpy l\u00fdtka<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>T\u011bhotensk\u00fd\u00a0a premenstrua\u010dn\u00ed<\/span><\/td>\n<td height=\"24\"><span>zadr\u017eov\u00e1n\u00ed sod\u00edku + zv\u00fd\u0161en\u00e1 kapil\u00e1rn\u00ed propustnost pro b\u00edlkovinu<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Alergick\u00fd (Quinckeho)<\/span><\/td>\n<td height=\"24\"><span>dilatace arteriol a prekapil\u00e1rn\u00edch sv\u011bra\u010d\u016f + venokonstrikce + zv\u00fd\u0161en\u00ed kapit\u00e1rn\u00ed propustnosti p\u016fsoben\u00edm alergenu<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Pol\u00e9kov\u00fd (iatrogenn\u00ed)<\/span><\/td>\n<td height=\"24\"><span>r\u016fzn\u00fd mechanismus podle druhu l\u00e9ku<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Srde\u010dn\u00ed<\/span><\/td>\n<td height=\"24\"><span>sn\u00ed\u017een\u00ed srde\u010dn\u00edho v\u00fddeje + neurohumor\u00e1ln\u00ed zm\u011bny + zadr\u017een\u00ed vody a miner\u00e1l\u016f<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Ledvinn\u00fd<\/span><\/td>\n<td height=\"24\"><span>zadr\u017een\u00ed vody a miner\u00e1l\u016f, hypoproteinemie<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Jatern\u00ed<\/span><\/td>\n<td height=\"24\"><span>perifern\u00ed vazodilatace + neurohumor\u00e1ln\u00ed zm\u011bny<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Hypoproteinemick\u00fd\u00a0(hypoalbuminemie, an\u00e9mie)<\/span><\/td>\n<td height=\"24\"><span>pokles onkotick\u00e9ho tlaku plazmy<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>\u017diln\u00ed<\/span><\/td>\n<td height=\"24\"><span>porucha \u017eiln\u011b-svalov\u00e9 pumpy, \u017eiln\u00ed hypertenze<\/span><\/td>\n<\/tr>\n<tr>\n<td height=\"24\"><span>Prim\u00e1rn\u00ed lymfatick\u00fd<\/span><\/td>\n<td height=\"24\"><span>porucha v\u00fdvoje lymfatick\u00fdch c\u00e9v + asymptomatick\u00fd z\u00e1n\u011bt? Liped\u00e9m nahromad\u011bn\u00ed tukov\u00e9 tk\u00e1n\u011b v podko\u017e\u00ed p\u0159i gynoidn\u00ed obezit\u011b<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\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\"><strong><span style=\"color: #ffffff;\">Oboustrann\u00e9 otoky doln\u00edch kon\u010detin<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center; width: 150px;\"><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<\/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 height=\"24\">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 (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? Liped\u00e9m 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<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\" height=\"25\"><strong><span style=\"color: #ffffff;\">Jednostrann\u00e9 otoky doln\u00edch kon\u010detin<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 150px; height: 25px; text-align: center;\"><strong>Otok<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>P\u0159\u00ed\u010dina<\/strong><\/td>\n<\/tr>\n<tr>\n<td><span>Flebotromb\u00f3za<\/span><\/td>\n<td>ucp\u00e1n\u00ed hlubok\u00fdch \u017eil doln\u00ed kon\u010detiny<\/td>\n<\/tr>\n<tr>\n<td><span>Tromboflebitida<\/span><\/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\u011b- lan\u00e9 flebotromb\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<br \/>\n= vrozen\u00fd lymfatick\u00fd otok, po\u0161kozen\u00ed perifern\u00edch lymfatick\u00fdch c\u00e9v a uzlin<br \/>\n= sekund\u00e1rn\u00ed lymfatick\u00fd otok, porucha v\u00fdvoje lymfatick\u00fdch c\u00e9v + asymptomatick\u00fd z\u00e1n\u011bt?<br \/>\n= prim\u00e1rn\u00ed lymfatick\u00fd otok<\/td>\n<\/tr>\n<tr>\n<td><span>\u017diln\u00ed<\/span><\/td>\n<td>porucha \u017eiln\u011b-svalov\u00e9 pumpy, \u017eiln\u00ed hypertenze<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5>4.3.3 Laboratorn\u00ed diagnostika \u017eiln\u00edch onemocn\u011bn\u00ed<\/h5>\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.<\/p>\n<p style=\"text-align: justify;\">D\u016fvodem ultrazvukov\u00e9ho vy\u0161et\u0159en\u00ed v t\u00e9to f\u00e1zi mohou b\u00fdt:<\/p>\n<ol>\n<li>\u00a0netypick\u00e9 subjektivn\u00ed pot\u00ed\u017ee,<\/li>\n<li>nev\u00fdrazn\u00fd objektivn\u00ed n\u00e1lez,<\/li>\n<li>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>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>podez\u0159en\u00ed na vrozen\u00e9 \u017eiln\u00ed malformace.<\/li>\n<\/ol>\n<p 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.<\/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.<\/p>\n<p style=\"text-align: justify;\">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.<\/p>\n<p style=\"text-align: justify;\">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><strong>Nep\u0159\u00edm\u00e9 diagnostick\u00e9 metody<\/strong>\n<ol>\n<li style=\"text-align: justify;\"><strong>Impedan\u010dn\u00ed pletyzmografie (IPG)<\/strong><br \/>\nImpedan\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\u0159itromb\u00f3ze objem krve zv\u011bt\u0161uje a elektrick\u00fd odporkles\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.S n\u00e1stupem ultrazvukov\u00fdch vy\u0161et\u0159ovac\u00edch metod ztratila IPG v diagnostice flebotromb\u00f3zy sv\u016fj v\u00fdznam.<\/li>\n<li style=\"text-align: justify;\"><strong>D-\u00addim\u00e9ry<\/strong><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\u00e9mukoagulace a tak\u00e9 fibrinol\u00fdzy.Stupe\u0148 zv\u00fd\u0161en\u00ed D-dim\u00e9r\u016f odr\u00e1\u017e\u00ed rozsah trom-b\u00f3zy, trv\u00e1n\u00ed p\u0159\u00edznak\u016f a pou\u017eit\u00ed antikoagula\u010dn\u00edl\u00e9\u010dby. <b>Vysok\u00e1 hladina D\u00addim\u00e9r\u016f <\/b>sv\u011bd\u010d\u00ed prov\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\u00ad-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 tromboembolic\u00adk\u00e9 nemoci<\/b>.<\/li>\n<\/ol>\n<\/li>\n<li><strong><span style=\"text-align: justify;\">P\u0159\u00edm\u00e9 diagnostick\u00e9 metody<\/span><\/strong>\n<ol>\n<li style=\"text-align: justify;\"><strong>Rentgenov\u00e1 venografie<\/strong> (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 nepohod l\u00edpro 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.Hlubok\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>Ascendentn\u00ed <\/b><strong>flebogra\u00adfie <\/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. Pokud je pot\u0159eba zobrazit \u017eiln\u00ed syst\u00e9m ve v\u011bt\u0161\u00edvzd\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 sevy\u0161et\u0159uj\u00ed ky\u010deln\u00ed \u017e\u00edly, horn\u00ed a doln\u00ed dut\u00e1 \u017e\u00edla (kavografie) a jejich p\u0159\u00edtoky.\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 style=\"text-align: justify;\"><strong>Radioizotopov\u00e9 vy\u0161et\u0159ovac\u00ed metody\u00a0<\/strong><br \/>\nRadioizotopy 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 vizu\u00ad alizace trombu zna\u010den\u00fdmi trombocyty nebo fibrinogenem. Trombocyty zna\u010den\u00e9 techneciem\u00a099m maj\u00ed 80\u201390 % pozitivn\u00ed prediktivn\u00ed hodnotu.<\/li>\n<li style=\"text-align: justify;\"><strong>Ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed\u00a0<\/strong><br \/>\nOd 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><\/li>\n<li style=\"text-align: justify;\"><b><\/b><strong>CT flebografie<\/strong><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 style=\"text-align: justify;\">Magnetick\u00e1 rezonance (MrI \u2013 magnetic re\u00adsonance imaging) a magnetick\u00e1 rezonan\u010dn\u00ed\u00a0venografie (MrV \u2013 magnetic resonance venography)\u00a0MR 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 MRI 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<table class=\"CSSTableGenerator\" style=\"width: 100%;\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\"><strong><span style=\"color: #ffffff;\">Tabulka 1<\/span><\/strong><br \/>\n<strong><span style=\"color: #ffffff;\">P\u0159ehled pou\u017e\u00edvan\u00fdch venofarmak<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" colspan=\"2\"><strong>1. VENOFARMAKA NA B\u00c1ZI P\u0158\u00cdRODN\u00cdCH L\u00c1TEK<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 60%; text-align: center;\"><strong>\u00da\u010dinn\u00e1 l\u00e1tka<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>N\u00e1zev l\u00e9ku<\/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.\u00a0 20 mg<br \/>\nAescin-Teva tbl. 20 mg<br \/>\nYellon cps.\u00a0 20 mg<\/td>\n<\/tr>\n<tr>\n<td>Aescin + anthokyanosidy z bor\u016fvek<br \/>\n+ v\u00fdta\u017eek z listnatce bodlinat\u00e9ho (Ruscus aculeatus)<br \/>\n+ v\u00fdta\u017eek z gotu kola (Centella asiatica)<\/td>\n<td>Varixinal tbl.<\/td>\n<\/tr>\n<tr>\n<td><em>Flavonoidy (bioflavonoidy, bioflavonoidn\u00ed glykosidy, vitamin P)<\/em><\/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.\u00a0 180 mg<\/td>\n<\/tr>\n<tr>\n<td>Hesperidin \u2013 v\u00fdta\u017eek z oplod\u00ed pomeran\u010d\u016f<br \/>\nHesperidin (+ diosmin = dehydrohesperidin \u2013 syntetick\u00fd deriv\u00e1t hesperidinu)<\/td>\n<td>Detralex tbl<\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td><\/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>Rutosidy\u00a0(vznikaj\u00ed chemickou modifikac\u00ed p\u0159\u00edrodn\u00edho rutinu)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>Troxerutin = oxerutin (hydroxyethylrutosid)<\/td>\n<td>Cilkanol cps. 300 mg<br \/>\nVenoruton cps. 300 mg<br \/>\nVenoruton F cps. 500 mg<\/td>\n<\/tr>\n<tr>\n<td>Troxerutin (+ 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(s\u016fl kyseliny dihydroxybenzensulfonov\u00e9)<\/td>\n<td>Doxium tbl.\u00a0 500 mg<br \/>\nDanium tbl.\u00a0 250 mg<br \/>\nDobica tbl.\u00a0 250 mg<\/td>\n<\/tr>\n<tr>\n<td>Heptaminol (+ troxerutin + ginkgo biloba)<\/td>\n<td>Ginkor Fort cps.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">N\u00edzkopr\u016ftokov\u00e9 <b>\u017eiln\u00ed malformace <\/b>na <i><b>prost\u00e9m sn\u00edmku <\/b><\/i>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<h5>4.4 L\u00e9\u010dba \u017eiln\u00edch onemocn\u011bn\u00ed<\/h5>\n<h5>4.4.1 Konzervativn\u00ed l\u00e9\u010dba \u2013\u00a0venofarmaka<\/h5>\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). 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<h5>4.4.2 Antikoagula\u010dn\u00ed l\u00e9\u010dba<\/h5>\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>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).<\/p>\n<p style=\"text-align: justify;\">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 aPTT1, 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 INR2\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;\"><strong><span style=\"color: #ffffff;\">Tabulka 2<\/span><\/strong><br \/>\n<strong><span style=\"color: #ffffff;\">Hepariny<\/span><\/strong><\/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),\u00a0aktivn\u00ed v\u0159edov\u00e1 choroba gastroduoden\u00e1ln\u00ed, trombocytopatie, t\u011b\u017ek\u00e1 arteri\u00e1ln\u00ed hypertenze, t\u011b\u017ek\u00e9\u00a0po\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\u00a0transamin\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,\u00a0\u00fa\u010dinek heparinu sni\u017euj\u00ed antihistaminika, kardioglykosidy a tetracyklinov\u00e1 antibiotika<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td>\n<p style=\"text-align: center;\"><strong><span style=\"color: #ffffff;\">Tabulka 3<\/span><\/strong><br \/>\n<strong><span style=\"color: #ffffff;\">Vlastnosti n\u00edzkomolekul\u00e1rn\u00edch heparin\u016f (LMWH)<\/span><\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>lep\u0161\u00ed biologick\u00e1 dostupnost ve srovn\u00e1n\u00ed s nefrakcionovan\u00fdm heparinem<\/li>\n<li>del\u0161\u00ed polo\u010das ne\u017e nefrakcionovan\u00fd heparin (pod\u00e1v\u00e1n\u00ed ka\u017ed\u00fdch 12\u201324 hodin)<\/li>\n<li>vy\u0161\u0161\u00ed anti-Xa aktivita ne\u017e anti-IIa aktivita (\u010d\u00e1ste\u010dn\u011b selektivn\u00ed blok\u00e1tory aktivovan\u00e9ho f. X)<\/li>\n<li>men\u0161\u00ed inhibice desti\u010dkov\u00fdch funkc\u00ed (ni\u017e\u0161\u00ed riziko krv\u00e1cen\u00ed)<\/li>\n<li>mal\u00fd vliv na koagula\u010dn\u00ed testy<\/li>\n<li>nelze je pln\u011b neutralizovat protamin sulf\u00e1tem<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"3\"><span style=\"color: #ffffff;\"><strong>Tabulka 4<\/strong><\/span><br \/>\n<span style=\"color: #ffffff;\"> <strong> D\u00e1vkov\u00e1n\u00ed nej\u010dast\u011bji pou\u017e\u00edvan\u00fdch LMWH v \u010cR<\/strong><\/span><\/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\u00adXa aktivita)<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>D\u00e1vkov\u00e1n\u00ed (mg\u00a0nebo 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 colspan=\"3\"><em>(Broul\u00edkov\u00e1, 2008)<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><em>\u00a0<\/em><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"5\"><span style=\"color: #ffffff;\"><strong>Tabulka 5<\/strong><\/span><br \/>\n<span style=\"color: #ffffff;\"><strong>Doporu\u010den\u00e9 d\u00e1vkov\u00e1n\u00ed LMWH u t\u011bhotn\u00fdch \u017een podle t\u011blesn\u00e9 hmotnosti a rizika TEN<\/strong><\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\"><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>pod 50 kg<\/td>\n<td>50\u201390 kg<\/td>\n<td>nad 90 kg<\/td>\n<td>velmi vysok\u00e9 riziko TEN<\/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><em>(Marik, 2008)<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>ANTAGONIST\u00c9 VITAMINU K (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.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 style=\"text-align: justify;\"><strong>Syntetick\u00e9 deriv\u00e1ty hirudinu (lepirudin, desiru\u00addin, 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.<br \/>\nHirudin s\u00e1m nemohl b\u00fdt v hum\u00e1nn\u00ed medic\u00edn\u011b prosvou 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 jenutn\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\u00ed-ho syndromu. Desirudin (Revasc) ke kr\u00e1tkodob\u00e9 tromboprofylaxi p\u0159i tot\u00e1ln\u00ed endoprot\u00e9ze ky\u010deln\u00ed-ho 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 (perkut\u00e1nn\u00ed translumin\u00e1rn\u00ed koron\u00e1rn\u00ed angioplastika) pro akutn\u00ed koron\u00e1rn\u00ed syndrom.<\/li>\n<li><strong>Argatroban<\/strong><br \/>\nTento n\u00edzkomolekul\u00e1rn\u00ed deriv\u00e1t argininu se neko-valentn\u011b v\u00e1\u017ee na aktivn\u00ed m\u00edsto trombinu, s n\u00edm\u017evytv\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.<\/li>\n<li>Gatrany<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).<\/li>\n<\/ol>\n<h6>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>HEPARINEM VYVOLAN\u00c1 TROMBOCYTOPENIE\u00a0(HIT = HEPARIN-INDUCED THROMBOCYTOPENIA)<\/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.<\/p>\n<p style=\"text-align: justify;\">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 100 000 mm3. 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<h5>4.4.3 Chirurgick\u00e1 terapie<\/h5>\n<h6>4.4.3.1 Chirurgie povrchov\u00fdch \u017eil<\/h6>\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 vena saphena magna et parva (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>INDIKACE K CHIRURGICK\u00c9 L\u00c9\u010cB\u011a:<\/h6>\n<ul>\n<li>subjektivn\u00ed pot\u00ed\u017ee nemocn\u00e9ho,<\/li>\n<li>p\u0159edejit\u00ed komplikac\u00edm varix\u016f,<\/li>\n<li>kosmetick\u00e9 hledisko,<\/li>\n<li>thrombophlebitis superficialis.<\/li>\n<\/ul>\n<p>KONTRAINDIKACE:<\/p>\n<ul>\n<li>akutn\u00ed hlubok\u00e1 \u017eiln\u00ed tromb\u00f3za,<\/li>\n<li>z\u00e1n\u011btliv\u00fd proces k\u016f\u017ee doln\u00edch kon\u010detin,<\/li>\n<li>gravidida,<\/li>\n<li>v\u011bk nad 70 let,<\/li>\n<li>t\u011b\u017ek\u00e9 aterotrombotick\u00e9 zm\u011bny tepen doln\u00edch kon\u010detin,<\/li>\n<li>v\u0161eobecn\u00e9 kontraindikace operace,<\/li>\n<li><em>(akutn\u00ed tromboflebitida).<\/em><\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Akutn\u00ed tromboflebitida je indikac\u00ed k chirurgick\u00e9mu \u0159e\u0161en\u00ed tehdy, jedn\u00e1-li se o flebitis VSM, kter\u00e1 se propaguje k \u00fast\u00ed do v. femoralis. Zde je nebezpe\u010d\u00ed embolizace.<\/p>\n<h6>P\u0158EDOPERA\u010cN\u00cd P\u0158\u00cdPRAVA<\/h6>\n<p style=\"text-align: justify;\">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>4.4.3.1.1 Striping VSM<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_196.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed\" alt=\"Obr. 10 \u2013 Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_196.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10 \u2013 Ozna\u010den\u00ed varix\u016f p\u0159ed operac\u00ed<\/p><\/div>\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,\u00a0dostate\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. H-variantu, 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\u00ed-li 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 traumatizacis 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>4.4.3.1.2 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. Je-li 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.<\/p>\n<p style=\"text-align: justify;\">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. Tu 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>FLEBEKTOMIE Z MINIINCIZ\u00cd<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_199.png\"><img decoding=\"async\" title=\"Obr. 11 \u2013 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplita\" alt=\"Obr. 11 \u2013 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplita\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_199.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11 \u2013 Vy\u00fast\u011bn\u00ed VSP s v\u011btv\u00ed do v. poplita<\/p><\/div>\n<p style=\"text-align: justify;\">Techniku flebektomie z miniinciz\u00ed propracoval dermatolog Muller. Pou\u017e\u00edval jemn\u00e9 h\u00e1\u010dky, kter\u00fdmi z bodov\u00e9 incize zachytil v\u00e9nu a luxoval ji do r\u00e1ny. N\u00e1sledn\u011b ji extrahoval za pomoci mal\u00e9ho pe\u00e1nu. Incize maj\u00ed velikost od 1 do 4 mm. Men\u0161\u00ed nejsou uzav\u00edr\u00e1ny v\u016fbec, v\u011bt\u0161\u00ed n\u00e1plas\u0165ov\u00fdm stehen. Tento postup redukuje periopera\u010dn\u00ed trauma, a sni\u017euje tak n\u00e1roky na analgezii p\u0159i i po operaci. Je prov\u00e1d\u011bn v lok\u00e1ln\u00ed anestezii, b\u011bhem v\u00fdkonu b\u00fdv\u00e1 doporu\u010dov\u00e1na elevace doln\u00edch kon\u010detin nad \u00farove\u0148 srdce s c\u00edlem zajistit vypr\u00e1zdn\u011bn\u00ed \u017eil. Kosmetick\u00fd efekt je v\u00fdborn\u00fd. Na rozd\u00edl od sklerotizace lze operovat i v takov\u00fdch oblastech, kde je sklerotizace riskantn\u00ed, nap\u0159\u00edklad v oblasti vnit\u0159n\u00edho kotn\u00edku nebo\u00a0dorza nohy. Nev\u00fdhodou je \u010dasov\u00e1 n\u00e1ro\u010dnost. K takov\u00e9mu postupu je nutno m\u00edt vhodn\u00e9 instrument\u00e1rium (h\u00e1\u010dky dle Oesche, Rameleta, Tretbara, Mullera \u010di Varadyho).<\/p>\n<h6>KRYOCHIRURGIE<\/h6>\n<p style=\"text-align: justify;\">Nepat\u0159\u00ed mezi roz\u0161\u00ed\u0159en\u00e9 postupy. P\u0159i kryostripingu je kryosonda zavedena do kmene v\u00e9ny a p\u016fsoben\u00edm chladu se st\u011bna \u017e\u00edly nalep\u00ed na sondu, se kterou je n\u00e1sledn\u011b invagina\u010dn\u00edm stripingem odstran\u011bna (intralumin\u00e1ln\u00ed kryostriping). U mal\u00fdch varix\u016f lze k v\u00e9n\u011b zav\u00e9st sondu a aplikac\u00ed chladu ji p\u0159eru\u0161it, fixovat k sond\u011b a odstranit (extralumin\u00e1ln\u00ed striping). K p\u0159ednostem kryochirurgie pat\u0159\u00ed bezkrevnost a mo\u017enost proveden\u00ed i po p\u0159edchoz\u00ed sklerotizaci VSM. Vzhledem k tomu, \u017ee odpadaj\u00ed incize p\u0159i dist\u00e1ln\u00edm konci sondy a p\u0159i odstra\u0148ov\u00e1n\u00ed postrann\u00edch v\u011btv\u00ed, zkracuje se i doba operace a celkov\u00e1 d\u00e9lka hospitalizace.<\/p>\n<h6>ENDOVASKUL\u00c1RN\u00cd METODY<\/h6>\n<p style=\"text-align: justify;\">Spo\u010d\u00edvaj\u00ed v termick\u00e9m po\u0161kozen\u00ed v\u00e9ny s jej\u00ed n\u00e1slednou obliterac\u00ed. Do v\u00e9ny se pod ultrazvukovou kontrolou zavede sonda, kter\u00e1 v\u00e9nu po\u0161kod\u00ed p\u0159em\u011bnou radiofrekven\u010dn\u00edho proudu (VNUS Closure) nebo sv\u011bteln\u00e9ho paprsku (endoven\u00f3zn\u00ed laser) v termickou energii.<\/p>\n<h6>4.4.3.1.3 Jednodenn\u00ed a ambulantn\u00ed chirurgie<\/h6>\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 (radiofrekven\u010dn\u00ed) 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\u00ed-li 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>4.4.3.1.4 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. Je-li 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 style=\"text-align: justify;\">Endoskopick\u00e1 subfasci\u00e1ln\u00ed disekce perfor\u00e1tor\u016f \u2013ESDP (Subfascial Endoscopic Perforator Surgery\u2013 SEPS, Endoscopic Subfascial Division of Perforating veins \u2013 ESDP, die endoskopische subfaszialeDiszision der Perforansvenen \u2013 ESDP)<\/li>\n<li>Sklerotizace<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<ol>\n<li style=\"text-align: justify;\"><strong>Otev\u0159en\u00e1 ligatura<\/strong><br \/>\n<span style=\"text-align: justify;\">Subfasci\u00e1ln\u00ed disekci a ligaturu perfor\u00e1tor\u016f poprv\u00e9popsal <\/span><b style=\"text-align: justify;\">Linton <\/b><span style=\"text-align: justify;\">v roce 1938 jako metodu vhodnouk 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 a\u017e k zevn\u00edmu kotn\u00edku a subfasci\u00e1ln\u00ed ligaturu v\u0161ech vv.perforantes na b\u00e9rci z dlouh\u00e9ho pod\u00e9ln\u00e9ho \u0159ezu.<br \/>\nV\u00fdkon zakon\u010dil resekc\u00ed \u010d\u00e1sti fascie a jej\u00edm stehem.Linton podvazuje perfor\u00e1tory subfasci\u00e1ln\u011b, <\/span><strong style=\"text-align: justify;\">Coc\u00adkett <\/strong><span style=\"text-align: justify;\">extrafasci\u00e1ln\u011b. Cockett vede dlouh\u00fd \u0159ez na me<\/span><span style=\"text-align: justify;\">di\u00e1ln\u00ed plo\u0161e dist\u00e1ln\u00ed t\u0159etiny b\u00e9rce, za hranou tibiae.<br \/>\nJe-li p\u0159\u00edtomen ulcus cruris, tak jej exciduje. Cel\u00fdv\u00fdkon je extrafasci\u00e1ln\u00ed. Tato metoda byla mnoha dal\u0161\u00edmi autory modifikov\u00e1na. <\/span><b style=\"text-align: justify;\">Doddova <\/b><span style=\"text-align: justify;\">modifikace spo\u010d\u00edvala v subfasci\u00e1ln\u00edm podvazu perfor\u00e1tor\u016f. Roz\u0161\u00ed\u0159en\u00e1 je <\/span><b style=\"text-align: justify;\">segment\u00e1ln\u00ed Cockettova operace<\/b><span style=\"text-align: justify;\">, 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. V roce 1955 popsal <\/span><b style=\"text-align: justify;\">Felder <\/b><span style=\"text-align: justify;\">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.<\/span><\/li>\n<li style=\"text-align: justify;\"><strong>Endoskopick\u00e1 disekce<\/strong><br \/>\nP\u0159edch\u016fdcem dne\u0161n\u00edch endoskopick\u00fdch postup\u016f byla endoskopick\u00e1 obliterace Cockettov\u00fdch perfor\u00e1tor\u016f pomoc\u00ed laryngoskopu, kterou v roce 1972popsal <b>Bentley<\/b>.<br \/>\nV\u00fdkon prov\u00e1d\u011bl v celkov\u00e9 anestezii, z pod\u00e9ln\u00e9ho \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 a osv\u011btlen\u00fdm laryngoskopem ji elevoval. Perfor\u00e1tory uzav\u00edral Cushingov\u00fdmi klipy.Metoda v\u0161ak doznala v\u011bt\u0161\u00edho roz\u0161\u00ed\u0159en\u00ed a\u017e v roce 1985 d\u00edky <b>Hauerovi<\/b>, kter\u00fd pou\u017eil nov\u011b vyvinut\u00e9 instrumentarium firmy Wolf. V sou\u010dasnosti je aparatura nab\u00edzena v\u00edce firmami, p\u0159i\u010dem\u017e mezi nimi nejsou podstatn\u00e9 rozd\u00edly. A\u017e na v\u00fdjimky jsou v\u0161echny p\u0159\u00edstroje napojeny na obrazovku s mo\u017enost\u00ed videoz\u00e1znamu.Operat\u00e9r s asistentem stoj\u00ed na stran\u011b operovan\u00e9 kon\u010detiny, video pak u nohou pacienta. Incizi, cca3 cm dlouhou, provedeme na ventromedi\u00e1ln\u00ed plo\u0161e b\u00e9rce v jeho horn\u00ed polovin\u011b. Mus\u00ed b\u00fdt um\u00edst\u011bna do zdrav\u00e9 k\u016f\u017ee, prost\u00e9 trofick\u00fdch zm\u011bn, kter\u00e9 jsou v\u017edy p\u0159\u00edtomny u pacient\u016f s CVI indikovan\u00fdch k ESDP. Vhodn\u00e9 je incidovat k\u016f\u017ei nad varik\u00f3zn\u00edm uzlem, kter\u00fd je sou\u010dasn\u011b odstran\u011bn. Pronik\u00e1me k 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,kde 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.Nejd\u0159\u00edve zav\u00e1d\u00edme tubus mezi fascii a sval a tup\u011b je od sebe odd\u011blujeme, pot\u00e9 je do tubusu zasunuta kamera.<br \/>\nAplikujeme 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 svisle prob\u00edhaj\u00edc\u00ed v\u00e9ny mezi svalem a fasci\u00ed. Pod p\u0159\u00edmou kontrolou zrakem je koagulujeme a prot\u00edn\u00e1me.Za 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 style=\"text-align: justify;\"><strong>Sklerotizace<\/strong><br \/>\nSklerotizaci perfor\u00e1tor\u016f neprov\u00e1d\u00edme pro riziko pr\u016fniku sklerotiza\u010dn\u00edho roztoku do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu.<\/li>\n<\/ol>\n<h6>4.4.3.1.5 Komplikace chirurgick\u00e9 terapie<\/h6>\n<p style=\"text-align: justify;\">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 style=\"text-align: justify;\"><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 operace a sou\u010dasn\u011b s n\u00edm nakl\u00e1d\u00e1me elastickou band\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 z hlediska prevence vzniku hematomu v r\u00e1n\u011b.<\/li>\n<li style=\"text-align: justify;\"><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 nebo ve fossa poplitea. M\u016f\u017ee nastat jednak m\u00e9n\u011b z\u00e1va\u017en\u00e9 krv\u00e1cen\u00ed z poran\u011bn\u00ed v\u011btv\u00ed bulbu \u010di samotn\u00e9 safeny, 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 ne\u017e tepny. Je pops\u00e1na ligatura femor\u00e1ln\u00ed i poplite\u00e1ln\u00ed arterie i striping tepny.Poran\u011bn\u00ed v\u011btv\u00ed bulbu a samotn\u00e9 safeny \u0159e\u0161\u00edme ligaturou, poran\u011bn\u00ed femor\u00e1ln\u00edch c\u00e9v pak stehem. P\u0159i stav\u011bn\u00ed krv\u00e1cen\u00ed je nutno postupovat velmi \u0161etrn\u011b, abychom nezp\u016fsobili dal\u0161\u00ed \u0161kody, nap\u0159\u00edklad nalo\u017een\u00edm pe\u00e1n\u016f naslepo. Krv\u00e1cen\u00ed v\u017edy nejd\u0159\u00edve zastav\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 nad a pod l\u00e9z\u00ed.P\u0159i v\u011bt\u0161\u00edm po\u0161kozen\u00ed, podvazu nebo prot\u011bt\u00ed hlubok\u00e9 v\u00e9ny se \u0159\u00edd\u00edme z\u00e1sadami c\u00e9vn\u00ed chirurgie. Poran\u011bn\u00ed velk\u00fdch c\u00e9v by se nem\u011blo vyskytovat. V\u017edy mus\u00edme pe\u010dliv\u011b vypreparovat \u00fast\u00ed VSM\/VSP do hlubok\u00e9ho \u017eiln\u00edho syst\u00e9mu. Jsme-li na pochyb\u00e1ch, nikdy nesm\u00edme v\u00e9nu podv\u00e1zat, nebo dokonce stripovat.<\/li>\n<li style=\"text-align: justify;\"><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<h6>POOPERA\u010cN\u00cd KOMPLIKACE<\/h6>\n<ol>\n<li style=\"text-align: justify;\"><strong>Hematom<br \/>\n<\/strong>Hematom se nej\u010dast\u011bji vyskytuje v oblasti ventromedi\u00e1ln\u00ed plochy b\u00e9rce a stehna, tj. v pr\u016fb\u011bhu velk\u00e9 safeny. 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 a vedle aplikace mast\u00ed a obvaz\u016f si m\u016f\u017ee vy\u017e\u00e1dat i incize a evakuace.Prevenc\u00ed je \u0161etrn\u00e1 opera\u010dn\u00ed technika, nakl\u00e1d\u00e1n\u00ed elastick\u00e9 band\u00e1\u017ee sou\u010dasn\u011b se stripingem tam, kde je to mo\u017en\u00e9. U rozs\u00e1hlej\u0161\u00edch v\u00fdkon\u016f je nutn\u00e1 peropera\u010dn\u00ed komprese, a\u0165 ji\u017e asistentem longetou p\u0159es k\u016f\u017ei nebo vsunut\u00edm longety do r\u00e1ny. Velkou i malou skrytou \u017e\u00edlu stripujeme v\u017edy a\u017e na konec operace a jen v takov\u00e9m rozsahu, kam a\u017e sahaj\u00ed patologick\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 c\u00e9v. Dal\u0161\u00ed p\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt sklouznut\u00ed ligatury.Je zde nebezpe\u010d\u00ed jeho infekce, a proto je nutn\u00e9 oblast t\u0159\u00edsla na konci operace d\u016fkladn\u011b zkontrolovat a vysu\u0161it. Mus\u00edme myslet i na tzv. \u201ezate\u010denou\u201c krev z kan\u00e1lu po odstran\u011bn\u00e9 velk\u00e9 safen\u011b.<\/li>\n<li style=\"text-align: justify;\"><strong>Neurologick\u00e9 komplikace<\/strong><br \/>\nNej\u010dast\u011bj\u0161\u00ed neurologickou komplikac\u00ed jsou parestezie v dist\u00e1ln\u00ed \u010d\u00e1sti ventromedi\u00e1ln\u00ed plochy b\u00e9rce,zp\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 je p\u0159\u00edtomno u tzv. limitovan\u00e9ho stripingu, kdy je VSM stripov\u00e1na jen pod koleno. Vy\u0161\u0161\u00ed procento pak u kompletn\u00edho stripingu od hlezna po t\u0159\u00edslo.Holme 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 stripingu.<br \/>\nVz\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 popsal Critchley p\u0159i operaci VSP. \u00dast\u00ed do v. poplitea bylo6 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 style=\"text-align: justify;\"><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 spo\u010d\u00edv\u00e1 v revizi a sutu\u0159e v lok\u00e1ln\u00ed anestezii nebo v 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 style=\"text-align: justify;\"><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 b\u00fdt v\u00fdskyt komplikovan\u00e9ho hojen\u00ed r\u00e1ny na b\u00e9rci,zejm\u00e9na u pacient\u016f s CVI v pokro\u010dil\u00e9m stadiu, kde jsou ji\u017e p\u0159\u00edtomny trofick\u00e9 zm\u011bny. V takov\u00fdch p\u0159\u00edpadech je nutno pacienty na mo\u017enost sekund\u00e1rn\u00edho hojen\u00ed r\u00e1ny upozornit p\u0159ed operac\u00ed.<\/li>\n<li style=\"text-align: justify;\">Tromboflebitida<br \/>\nVz\u00e1cn\u011b m\u016f\u017ee postihnout perifern\u00ed \u010d\u00e1st kmene VSM\/VSP p\u0159i limitovan\u00e9m stripingu nebo podvazu VSM nebo varixy, kter\u00e9 nebyly kompletn\u011b odstran\u011bny. Koagulum z v\u00e9ny exprimujeme po jej\u00ed Incizi nebo v\u00e9nu v lok\u00e1ln\u00ed anestezii exstirpujeme.<br \/>\nJeli proces rozs\u00e1hlej\u0161\u00ed, aplikujeme lok\u00e1ln\u011b antiflogistika a kompresivn\u00ed band\u00e1\u017e.<\/li>\n<li style=\"text-align: justify;\"><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\u00edsouvislost s u\u017e\u00edv\u00e1n\u00edm hormon\u00e1ln\u00edch prepar\u00e1t\u016f,v\u010detn\u011b kontraceptiv.<\/li>\n<li style=\"text-align: justify;\"><strong>Tetov\u00e1\u017e<\/strong><br \/>\nP\u0159i pou\u017eit\u00ed inkoustov\u00fdch tu\u017eek k p\u0159edopera\u010dn\u00edmu zna\u010den\u00ed varix\u016f je mo\u017eno se setkat se vznikem tetov\u00e1\u017ee. Sami jsme takovouto komplikaci nezaznamenali.<\/li>\n<\/ol>\n<h6>4.4.3.1.6 Reoperace<\/h6>\n<p style=\"text-align: justify;\">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.Recidiva 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.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.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\u00edli 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.<\/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.<\/p>\n<p style=\"text-align: justify;\">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 <i>in situ<\/i>. Tato situace nast\u00e1v\u00e1 tehdy, jestli\u017ee chirurgnesleduje 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\u201ehitchhike\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. Hvarianta. 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.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\u00fdchtenkost\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 navr\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\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 style=\"text-align: justify;\">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.V mal\u00e9m procentu se p\u0159\u00ed\u010dina recidivy nezjist\u00ed. Chceme-li zabr\u00e1nit vzniku recidivy, m\u011bli bychom dodr\u017eovat n\u00e1sleduj\u00edc\u00ed z\u00e1sady:<\/p>\n<ol>\n<li style=\"text-align: justify;\">P\u0159ed operac\u00ed pacienta d\u016fkladn\u011b vy\u0161et\u0159\u00edme (v\u017edy operat\u00e9r) a ozna\u010d\u00edme varixy a zejm\u00e9na m\u00edsta refluxu nesm\u00fdvatelnou tu\u017ekou.<\/li>\n<li style=\"text-align: justify;\">Ka\u017ed\u00e9ho pacienta vy\u0161et\u0159\u00edme duplexn\u00ed sonografi\u00ed,kterou prov\u00e1d\u00ed s\u00e1m operat\u00e9r nebo jeden zku\u0161en\u00fd l\u00e9ka\u0159. Vy\u0161et\u0159en\u00ed duplexn\u00ed sonografi\u00ed je pova\u017eov\u00e1no za zlat\u00fd standard, je zde ale mo\u017enost r\u016fzn\u00e9 interpretace v\u00fdsledk\u016f vy\u0161et\u0159en\u00ed.<\/li>\n<li style=\"text-align: justify;\">Pokud operaci neprov\u00e1d\u00ed erudovan\u00fd nebo c\u00e9vn\u00ed chirurg, m\u011bl by j\u00ed alespo\u0148 asistovat. Recidivu mus\u00ed operovat zku\u0161en\u00fd nebo c\u00e9vn\u00ed chirurg.<\/li>\n<li style=\"text-align: justify;\">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 incize nad jej\u00edm hmatn\u00fdm proxim\u00e1ln\u00edm koncem a 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 \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 \u00fast\u00ed VSM do VF a podv\u00e1\u017eeme v\u0161echny v\u011btve bulbu.<br \/>\nPot\u00e9 provedeme vysokou ligaturu VSM a do jej\u00edho perifern\u00edho pah\u00fdlu zavedeme 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. podkolenn\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 style=\"text-align: justify;\">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 style=\"text-align: justify;\">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 eliminovat. 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 style=\"text-align: justify;\">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.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 femor\u00e1ln\u00ed v\u00e9nu (VF) spolu s ponechan\u00fdm \u00fast\u00edm VSM. Vypreparujeme safenofemor\u00e1ln\u00ed \u00fast\u00ed, nalo\u017e\u00edme vysokou ligaturu (flush ligature) a VSM protneme.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\u0159\u00edstup ze standardn\u00edho \u0159ezu v t\u0159\u00edsle zvol\u00edme, jeli 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 style=\"text-align: justify;\">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 poplite\u00e1ln\u00ed v\u00e9ny (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\u00edli VSP v\u00fd\u0161e, m\u016f\u017eeme si pomoci flex\u00ed v kolenn\u00edm kloubu. T\u00edm se incize posune krani\u00e1ln\u011bji. 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<h4>4.5 Literatura<\/h4>\n<ol>\n<li style=\"text-align: justify;\">Bates SM. Treatment of deep venous thrombosis. N Eng J Med. 2004;351:452\u2013463.<\/li>\n<li style=\"text-align: justify;\">Bergan JJ. The Vein Book. Elsevier Academic Press Inc; 2007.<\/li>\n<li style=\"text-align: justify;\">Broul\u00edkov\u00e1 A. Antikogula\u010dn\u00ed l\u00e9\u010dba \u017eiln\u00ed tromb\u00f3zy. In: Eli\u0161ka O, Sp\u00e1\u010dil J, \u0160vrtinov\u00e1 V, edito\u0159i. Angio logie 2008. Trendy soudob\u00e9 angiologie. Praha: Gal\u00e9n; 2008. s. 41\u201345.<\/li>\n<li style=\"text-align: justify;\">Cronenwett JL, Johnston KW, editors. Ruther ford\u2019s Vascular Surgery. 7th Edition. Saunders El sevier; 2010.<\/li>\n<li style=\"text-align: justify;\">Ethunandan M, Mellor TK. Hemangiomas and vascular malformations of the maxillofacial region \u2013 a review. Br J Oral Maxillofac Surg. 2006; 44:263\u2013272.<\/li>\n<li style=\"text-align: justify;\">Firt P, Hejnal J, Van\u011bk I. C\u00e9vn\u00ed chirurgie. Praha: Karolinum; 2006.<\/li>\n<li style=\"text-align: justify;\">Glowiczki P. Handbook of Venous Disorders. 3rd Edition. Hodder Arnold; 2009.<\/li>\n<li style=\"text-align: justify;\">Heberer G, van Dongen RJAM. Gef\u00e4sschirurgie. Berlin Heidelberg New York: Springer-Verlag; 1987.<\/li>\n<li style=\"text-align: justify;\">Herman J, Duda M. Chronick\u00e1 ven\u00f3zn\u00ed insuficience pohledem miniinvazivn\u00edho chirurga. Prakt Flebol. 1999;8:49\u201360.<\/li>\n<li style=\"text-align: justify;\">Herman J, Lovecek M, Duda M, Svach I. A rare complication of varicose vein surgery. Phlebology. 2000;15:43\u201345.<\/li>\n<li style=\"text-align: justify;\">Herman J, Musil D. Klippel-Trenaunay syndrome associated with great saphenous vein aplasia. Phlebology. 2010;1:35\u201337.<\/li>\n<li style=\"text-align: justify;\">Kahn SR. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Int Med. 2004;164:17\u201326.<\/li>\n<li style=\"text-align: justify;\">Kaletov\u00e1 M, Musil D. Akutn\u00ed stavy ve flebologii. Int Med. 2006;9:380\u2013384.<\/li>\n<li style=\"text-align: justify;\">Lee BB, Laredo J, Lee TS, Huh S, Neville R. Ter minology and classification of congenital vascular malformations. Phlebology. 2007;22:249\u2013252.<\/li>\n<li style=\"text-align: justify;\">Lee BB, Bergan J, Glowiczki P, et al. Diagnosis and treatment of venous malformations. Consensus Document of the Internationeal Union of Phle bology (IUP)-2009. Int Angiol. 2009;28:434\u2013451.<\/li>\n<li style=\"text-align: justify;\">Lumley JSP, Hoballah JJ. Vascular Surgery. Berlin Heidelberg: Springer-Verlag; 2009.<\/li>\n<li style=\"text-align: justify;\">Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008; 359:2025\u20132031.<\/li>\n<li style=\"text-align: justify;\">Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 982;69:412\u2013422.<\/li>\n<li style=\"text-align: justify;\">Musil D. Rizika a prevence tromboembolick\u00e9 choroby. Med Pro Praxi. 2009;6(2):61\u201365.<\/li>\n<\/ol>\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":2447,"menu_order":4,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2958","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2958","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=2958"}],"version-history":[{"count":35,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2958\/revisions"}],"predecessor-version":[{"id":3089,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2958\/revisions\/3089"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2447"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2958"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}