{"id":2829,"date":"2023-02-10T11:31:05","date_gmt":"2023-02-10T11:31:05","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=2829"},"modified":"2023-02-24T12:41:55","modified_gmt":"2023-02-24T12:41:55","slug":"8-2-ulceracija-karotidnog-plaka","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=2829","title":{"rendered":"8.2. ULCERACIJA KAROTIDNOG PLAKA"},"content":{"rendered":"

\"\"<\/a><\/p>\n

<\/p>\n

INDIKACIJE ZA ENDARTEREKTOMIJU KOD SIMPTOMATSKE KAROTIDNE STENOZE<\/h1>\n

<\/a><\/h1>\n

\n

\n

8.2. ULCERACIJA KAROTIDNOG PLAKA<\/p>\n

<\/h3>\n<\/div>\n
\n

ULCERACIJA KAROTIDNOG PLAKA<\/strong>, bez ulceracije rizik je 17% za de\u0161ava rizik od ishemi\u010dkog mo\u017edanog udara,\u00a0 a sa ulceracijom, 30%).<\/p>\n

Karotidna<\/span> <\/span>endarterektomija<\/span> <\/span>je<\/span> <\/span>pre<\/span> <\/span>svega<\/span> <\/span>pro<\/span>fi<\/span>lakti\u010dka<\/span> <\/span>operacija<\/span> <\/span>(smanjenje<\/span> <\/span>rizika<\/span> <\/span>od<\/span> <\/span>mo\u017edanog<\/span> <\/span>udara).<\/span> <\/span>Terapijski<\/span> <\/span>efekat<\/span> <\/span>(spre\u010davanje<\/span> <\/span>novih<\/span> <\/span>TIA)<\/span> <\/span>je<\/span> <\/span>sekundaran.<\/span> <\/span>Zato<\/span> <\/span>mora<\/span> <\/span>imati<\/span> <\/span>jako<\/span> <\/span>mali<\/span> <\/span>perioperativni<\/span> <\/span>rizik.<\/span><\/p>\n

Maksimalno<\/span> <\/span>dozvoljeni<\/span> <\/span>perioperativni<\/span> <\/span>rizik:<\/span><\/p>\n

    \n
  • Za<\/span> <\/span>asimptomske<\/span> <\/span>bolesnike<\/span> <\/span>najve\u0107i<\/span> <\/span>prihvatljiv<\/span> <\/span>perioperacioni<\/span> <\/span>kombinovani<\/span> <\/span>morbiditet<\/span> <\/span>i<\/span> <\/span>mortalitet<\/span> <\/span>je<\/span> <\/span>3%;<\/span><\/li>\n
  • Za<\/span> <\/span>simptomske<\/span> <\/span>bolesnike<\/span> <\/span>(TIA)<\/span> <\/span>dozvoljeni<\/span> <\/span>rizik<\/span> <\/span>iznosi<\/span> <\/span>5%;<\/span><\/li>\n
  • Za<\/span> <\/span>bolesnike<\/span> <\/span>sa<\/span> <\/span>mo\u017edanim<\/span> <\/span>udarom<\/span> <\/span>rizik<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>do<\/span> <\/span>7%;<\/span><\/li>\n
  • Kod<\/span> <\/span>restenoze<\/span> <\/span>nakon<\/span> <\/span>karotidne<\/span> <\/span>endarterektomije<\/span> <\/span>kombinovani<\/span> <\/span>rizik<\/span> <\/span>od<\/span> <\/span>mortaliteta<\/span> <\/span>i<\/span> <\/span>morbiditeta<\/span> <\/span>ne<\/span> <\/span>sme<\/span> <\/span>biti<\/span> <\/span>ve\u0107i<\/span> <\/span>od<\/span> <\/span>10%<\/span><\/li>\n<\/ul>\n

    Ustanove<\/span> <\/span>sa<\/span> <\/span>ve\u0107im<\/span> <\/span>kombinovanim<\/span> <\/span>peroperativnim<\/span> <\/span>rizikom<\/span> <\/span>ne<\/span> <\/span>bi<\/span> <\/span>trebalo<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>bave<\/span> <\/span>ovom<\/span> <\/span>hirurgijom,<\/span> <\/span>ili:<\/span> <\/span>trebalo<\/span> <\/span>bi<\/span> <\/span>bitno<\/span> <\/span>da<\/span> <\/span>promene<\/span> <\/span>na\u010din<\/span> <\/span>svog<\/span> <\/span>rada.<\/span><\/p>\n

    V<\/span>e\u0107in<\/span>a<\/span> <\/span>neurolog<\/span>a<\/span> <\/span>(82%<\/span>)<\/span> <\/span>upu\u0107uj<\/span>e<\/span> <\/span>n<\/span>a<\/span> <\/span>operacij<\/span>u<\/span> <\/span>pacijent<\/span>a<\/span> <\/span>ukolik<\/span>o<\/span> <\/span>j<\/span>e<\/span> <\/span>stenoz<\/span>a<\/span> <\/span>ve\u0107a<\/span> <\/span>od<\/span> <\/span>70%.<\/span> <\/span>Manji<\/span> <\/span>broj<\/span> <\/span>anketiranih<\/span> <\/span>neurologa<\/span> <\/span>upu\u0107uju<\/span> <\/span>na<\/span> <\/span>hirur\u0161ku<\/span> <\/span>intervenciju<\/span> <\/span>pacijente<\/span> <\/span>sa<\/span> <\/span>karotidnom<\/span> <\/span>stenozom<\/span> <\/span>ispod<\/span> <\/span>60%,<\/span> <\/span>obi\u010dno<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>stenozirana<\/span> <\/span>i<\/span> <\/span>kontralateralna<\/span> <\/span>karotidna<\/span> <\/span>arterija<\/span>.<\/span><\/p>\n

    Indikacije<\/b><\/span> <\/b><\/span> <\/b><\/span>za <\/b><\/span> <\/b><\/span>hirur\u0161ko<\/b><\/span> <\/b><\/span> <\/b><\/span>le\u010denje<\/b><\/span> <\/b><\/span> <\/b><\/span>karotidne<\/b><\/span> <\/b><\/span> <\/b><\/span>bolesti<\/b><\/span> <\/b><\/span> <\/b><\/span>postavljaju<\/span> <\/span> <\/span>zajedno<\/span> <\/span>vaskularni<\/span> <\/span>hirurg,<\/span> <\/span>neurolog,<\/span> <\/span>kardiolog<\/span> <\/span>i<\/span> <\/span>anesteziolog.<\/span> <\/span>Razmatra<\/span> <\/span>se:<\/span><\/p>\n

      \n
    • Lokalizacija,<\/span> <\/span>karakter<\/span> <\/span>i<\/span> <\/span>stepen<\/span> <\/span>ateroskleroti\u010dne<\/span> <\/span>lezije,<\/span><\/li>\n
    • Stadijum<\/span> <\/span>ishemi\u010dkih<\/span> <\/span>o\u0161te\u0107enja<\/span> <\/span>mozga<\/span> <\/span>(neurolo\u0161ki<\/span> <\/span>status,<\/span> <\/span>CT<\/span> <\/span>mozga),<\/span><\/li>\n
    • Prisustvo<\/span> <\/span>konkomitiraju\u0107ih<\/span> <\/span>oboljenja,<\/span> <\/span>naro\u010dito<\/span> <\/span>kardiolo\u0161ki<\/span> <\/span>rizik.<\/span><\/li>\n<\/ul>\n

      Smisao<\/span> <\/span>karotidne<\/span> <\/span>endarterektomije<\/span> <\/span>je:<\/span> <\/span>prevencija<\/span> <\/span>mo\u017edanog<\/span> <\/span>udara,<\/span> <\/span>otklanjanje<\/span> <\/span>neurolo\u0161kih<\/span> <\/span>tegoba<\/span> <\/span>i<\/span> <\/span>spre\u010davanje<\/span> <\/span>vaskularne<\/span> <\/span>demencije,<\/span> <\/span>senilnosti<\/span> <\/span>itd.<\/span><\/p>\n

      Indikacije<\/b><\/span> <\/b><\/span>za<\/span> <\/span>hirur\u0161ko<\/span> <\/span>le\u010denje<\/span> <\/span>karotidne<\/span> <\/span>bolesti<\/span> <\/span>su:<\/span><\/p>\n

        \n
      • TIA<\/span> <\/span>sa<\/span> <\/span>hemisferi\u010dnom<\/span> <\/span>ili<\/span> <\/span>monokularnom<\/span> <\/span>(amaurosis<\/span> <\/span>fugax)<\/span> <\/span>simptomatologijom,<\/span> <\/span>i<\/span> <\/span>stenozom<\/span> <\/span>odgovaraju\u0107e<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>ve\u0107om<\/span> <\/span>od<\/span> <\/span>70%;<\/span> <\/span>utoliko<\/span> <\/span>pre<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>egzulcerisana,<\/span><\/li>\n
      • Hroni\u010dni<\/span> <\/span>neurolo\u0161ki<\/span> <\/span>ishemi\u010dki<\/span> <\/span>deficit<\/span> <\/span>stariji<\/span> <\/span>od<\/span> <\/span>mesec<\/span> <\/span>dana,<\/span> <\/span>sa<\/span> <\/span>stenozom <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>ve\u0107om<\/span> <\/span>od<\/span> <\/span>70%,<\/span><\/li>\n
      • Progresivni<\/span> <\/span>i<\/span> <\/span>regresivni<\/span> <\/span>ishemi\u010dki<\/span> <\/span>neurolo\u0161ki<\/span> <\/span>deficit<\/span> <\/span>(pod<\/span> <\/span>uslovom<\/span> <\/span>da<\/span> <\/span>je<\/span> <\/span>CT<\/span> <\/span>negativan),<\/span> <\/span>u<\/span> <\/span>prva<\/span> <\/span>4<\/span> <\/span>sata,<\/span> <\/span>kad<\/span> <\/span>postoji<\/span> <\/span>karotidna<\/span> <\/span>subokluzija,<\/span><\/li>\n
      • Asimptomatski<\/span> <\/span>pacijenti<\/span> <\/span>sa<\/span> <\/span>stenozom<\/span> <\/span>preko<\/span> <\/span>80%,<\/span> <\/span>i<\/span> <\/span>znacima<\/span> <\/span>ulceracije,<\/span> <\/span>posebno<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>planira<\/span> <\/span>druga<\/span> <\/span>velika<\/span> <\/span>operacija.<\/span><\/li>\n
      • Kinking<\/span> <\/span>i<\/span> <\/span>coiling<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>CT<\/span> <\/span>nalaz<\/span> <\/span>isklju\u010dio<\/span> <\/span>druge<\/span> <\/span>cerebralne<\/span> <\/span>lezije<\/span> <\/span>osim<\/span> <\/span>ishemi\u010dkih<\/span> <\/span>uz<\/span> <\/span>prisustvo<\/span> <\/span>fokalne<\/span> <\/span>simptomatologije.<\/span><\/li>\n<\/ul>\n<\/div>\n
        \n

        Kriterijumi operabiliteta su neurolo\u0161ki, angiolo\u0161ki i op\u0161ti.<\/strong><\/p>\n

        Neurolo\u0161ki kriterijumi operabiliteta:<\/strong> Pacijenti se smatraju simptomatskim ukoliko su u polednjih \u0161est meseci pretrpeli tranzitorni ishemi\u010dni atak (TIA) ili ishemi\u010dki mo\u017edani udar, kao posledicu oboljenja karotidnih arterija.6-16 U slu\u010daju sve\u017eeg neurolo\u0161kog deficita (mesec dana), naro\u010dito ako je CT nalaz pozitivan, rekonstruktivni zahvati se ne planiraju zbog mogu\u0107e konverzije ishemi\u010dnog u hemoragi\u010dni infarkt mozga.<\/p>\n

        Arterijski nalaz:<\/strong> inoperabilna je karotidna okluzija se propagacijom du\u017e intrakranijalnog segmenta.<\/p>\n

        Kriterijumi op\u0161teg operabiliteta<\/strong> podrazumevaju procenu o tome kako \u0107e bolesnik podneti operaciju. Zavise od op\u0161teg stanja, kao i funkcionalne rezerve kardio-respiratornog, nervnog, ekskretornog i drugih sistema. Posebnu pa\u017enju zahteva kardiolo\u0161ki status. Ukoliko se sumnja na arteritis (npr. Takayasu) neophodno je proveriti inflamatorne biomarkere uz serolo\u0161ka ispitivanja, da se izbegne operacija u aktivnoj fazi bolesti.<\/p>\n

        Stepen stenoze karotidnih arterija, u simptomatskih pacijenata, se ra\u010duna po \u201cMoneta\u201d (NASCET) kriterijumu: PSV odnos ACI\/ACC od 4 se identifikuje kao stenoza od 70%.17 Analizirani su svi podaci ECST, NASCET i \u201cVeterans Affairs\u201d klini\u010dkih studija i pra\u0107eno je oko 35000 pacijent-godina. Hirur\u0161ko le\u010denje je pokazalo znatno bolje rezultate kod pacijenata sa stenozom karotidne arterije od 70% ili vi\u0161e, sa simptomima cerebralne ishemije ( p<0. 001)18,19<\/p>\n

        Ameri\u010dka asocijacija za srce (AHA) karotidnoj endarterektomiji daje \u201cstepen A preporuke\u201d u simptomatskih pacijenata sa visoko-stepenom karotidnom stenozom, ako je stopa perioperativnog mo\u017edanog udara i smrti manja od 3%.12 U asimptomatskih pacijenata starosti ispod 75 godina, sa ultrazvu\u010dno opisanim su\u017eenjem dijametra karotidnih arterija od 70%, endarterektomija je prepolovila petogodi\u0161nji rizik od mo\u017edanog udara sa 12% na 6% (uklju\u010duju\u0107i i 3% perioperativnog rizika).<\/p>\n<\/div>\n

        \"\"
        \n\"\"<\/p>\n

        \n

        Poststenoti\u010dno hipoplasti\u010dna, skoro okludirana ACI, koja se vra\u0107a na normalan kalibar nakon endarterektomije<\/em><\/p>\n<\/div>\n

        \"\"<\/p>\n

        \n

        ontraindikacija za karotidnu endarterektomiju vrlo visokog rizika zbog oboljenja cerebralnih arterija.<\/em><\/p>\n

        Cerebralna MSCT arterigrafija prikazuje te\u0161ko deformisani willisov poligon sa doliho mega bazilarnom arterijom uz muralnu trombozu, sa okludiranom desnom vertebralnom arterijom<\/em><\/p>\n<\/div>\n

        \n
          \n
        • Operativo le\u010denje karotidne stenoze je apsolutno indikovano u simptomatskih pacijenata sa stenozom >70% (NASCET) i verovatno u pacijenata sa stenozom >50% (NASCET). Najve\u0107i perioperativni rizik mo\u017edani udar\/smrt bi trebalo da bude <6%.<\/strong><\/li>\n
        • Karotidna endarterektomija je kontraindikovana kod simptomatskih pacijenata sa stenozom manjom od 50%.<\/strong><\/li>\n
        • Karotidnu endarterektomiju bi trebalo u\u010diniti dve nedelje nakon posled- njih simptoma.<\/strong><\/li>\n
        • Endarterektomjia mo\u017ee biti u\u010dinjena kod visoko rizi\u010dnih pacijenata sa prihvatljivom stopom postoperativnog mo\u017edanog udara, kardiolo\u0161kih kom- plikacija i smtnog ishoda. Endarterektomija kod pacijenata starijih od 80 go- dina je pra\u0107ena prihvatljivom stopom neurolo\u0161kih i kardiolo\u0161kih komplikacija.<\/strong><\/li>\n
        • Kod asimptomatskih pacijenata sa ekstremno velikim rizikom (nekoliko udru\u017eenih te\u0161kih oboljenja), umesto invazivnog najbolji izbor bi bio medika- mentno le\u010denje.<\/strong><\/li>\n
        • Angioplastika karotidnih arterija je povezana sa ve\u0107im rizikom od embolizacije kod pacijenata starijih od 80 godina.<\/strong><\/li>\n
        • Kontraindikacija za karotidnu endarterektomiju vrlo visokog rizika zbog oboljenja cerebralnih arterija.<\/strong><\/li>\n
        • Cerebralna MSCT arterigrafija prikazuje te\u0161ko deformisani willisov poligon sa doliho mega bazilarnom arterijom uz muralnu trombozu, sa okludiranom desnom vertebralnom arterijom<\/strong><\/li>\n<\/ul>\n

          Prisustvo eholuscentnog plaka nagove\u0161tava predstoje\u0107e neurolo\u0161ke doga\u0111aje11-21 U identifikaciji vulnerabilnog karotidnog plaka se koristi Duplex ultrasonografija i biolo\u0161ki markeri. Denzitet plaka se mo\u017ee proceniti angiografijom sa kompjuterizovanom tomografijom upotrebom multidetektor skenera.18,19 Identifikovanje vulnerabilnog plaka mo\u017ee biti razlog vi\u0161e za endarterektomiju, pre nego za angioplastiku.<\/p>\n

          Biomarkeri za identifikaciju nestabilnog plaka i prete\u0107e rupture su C-reaktivni<\/p>\n

          protein, matriksne metaloproteinaze i njihovi inhibitori, rastvorljivi CD40 ligand, citokini, oksidisani LDL, lipoproteini povezani sa fosfolipazom A2, tip II sekretornih fosfolipaza A2, mijeloperoksidaza, monocit privla\u010de\u0107i protein 1 itd.20,21<\/p>\n

          Pre bilo kog invazivnog le\u010denja mora se razmotriti morfologija karotidnog plaka.<\/strong><\/p>\n

          Plakovi sa rizikom postproceduralne embolizacije moraju se identifikovati kvalitetnim Duplex ultrasonografskim pregledom ili biolo\u0161kim markerima.<\/p>\n

          Cerebralna protekcija koja se koristi tokom endovaskularne procedure ne mo\u017ee uticati na za\u0161titu od kasne embolizacije.<\/p>\n

          Redukcija kasnih komplikacija angioplastike posti\u017ee se selekcijom karot- idnih plakova niskog embolijskog potencijala.<\/p>\n<\/div>\n


          \n<\/p>\n","protected":false},"excerpt":{"rendered":"

          INDIKACIJE ZA ENDARTEREKTOMIJU KOD SIMPTOMATSKE KAROTIDNE STENOZE 8.2. ULCERACIJA KAROTIDNOG PLAKA ULCERACIJA KAROTIDNOG PLAKA, bez ulceracije rizik je 17% za de\u0161ava rizik od ishemi\u010dkog mo\u017edanog udara,\u00a0 a sa ulceracijom, 30%). Karotidna endarterektomija je pre svega profilakti\u010dka operacija (smanjenje rizika od mo\u017edanog udara). Terapijski efekat (spre\u010davanje novih TIA) je sekundaran. Zato mora imati jako mali perioperativni […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-2829","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n8.2. ULCERACIJA KAROTIDNOG PLAKA - KAROTIDNA HIRURGIJA<\/title>\n<meta name=\"description\" content=\"Bez ulceracije rizik je 17% za de\u0161ava rizik od ishemi\u010dkog mo\u017edanog udara sa ulceracijom, 30%) .Karotidna endarterektomija je pre svega profilakti\u010dka operacija (smanjenje rizika od mo\u017edanog udara). Terapijski efekat (spre\u010davanje novih TIA) je sekundaran. Zato mora imati jako mali perioperativni rizik.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.karotidnahirurgija.com\/?page_id=2829\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"8.2. 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