{"id":2872,"date":"2023-02-10T12:53:43","date_gmt":"2023-02-10T12:53:43","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=2872"},"modified":"2023-02-24T12:43:09","modified_gmt":"2023-02-24T12:43:09","slug":"9-indikacije-za-endarterektomiju-kod-asimptomatske-karotidne-stenoze","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=2872","title":{"rendered":"9. INDIKACIJE ZA ENDARTEREKTOMIJU KOD ASIMPTOMATSKE KAROTIDNE STENOZE"},"content":{"rendered":"

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

<\/p>\n

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

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

\n

All cases are unique and very similar to others.<\/p>\n

T.S. Eliot<\/em><\/p>\n

<\/div>\n

Experience dulls the edges of all our dogmas.<\/p>\n

Gilbert Murray<\/em><\/p>\n<\/div>\n

\n

Asimptomatska stenoza podrazumeva prisustvo stenoti\u010dnih lezija na karotidnoj bifurkaciji, u bolesnika koji jo\u0161 uvek nije imao simptome mo\u017edane ishemije.<\/strong><\/h4>\n

Te\u0161ke ateroskleroti\u010dne lezije karotidnog sliva mogu da ostanu bez simptoma zbog dobrog kolateralnog sistema (cervikalne, ekstrakranijalne, ekstrakranijalno- intrakranijalne i intrakranijalne anastomoze) i velike adaptabilnosti mozga u slu\u010daju postepenog razvoja ishemije. Odluka o na\u010dinu le\u010denja asimptomatske karotidne stenoze je vrlo delikatna. Mo\u017ee da se donese samo nakon kompletnih ispitivanja: angio-neurolo\u0161ki pregled, ulstrasonografija (ako je neophodno: arteriografija, CT, NMR).<\/p>\n

\"\"Kolateralni sistem mozga: veliki broj anastomoti\u010dnih grana i pleksiformnih spojeva mo\u017edanih arterija sa arterijama glave i vrata. Anastomoze mogu da se podele na: cervikalne, ekstrakranijalne, ekstrakranijalno- intrakranijalne i intrakranijalne.<\/em><\/p>\n

\n

Kolateralna cirkulacija izme\u0111u spolja\u0161nje i unutra\u0161nje karotidne arterije u slu\u010daju segmentne okluzije unutra\u0161nje karotidne arterije.<\/em><\/p>\n

\n<\/div>\n

\"\"<\/p>\n

\n

Asimptomatska karotidna stenoza se otkriva:<\/p>\n

    \n
  • Kao uzgredni<\/b> <\/b>nalaz<\/b> <\/b>ili<\/li>\n
  • Usklopu skrinin<\/b>g<\/b>p<\/b>r<\/b>ogram<\/b>a<\/b> <\/b>kadaciljanotragamozalezijamanakarotidnim arterijama kod rizi\u010dne populacije (auskultacija i ultrazvu\u010dni pregled).<\/li>\n<\/ul>\n

    Duplex-ultrasonografski skrining zahtevaju: pacijenti sa \u0161umom nad karotidnom arterijom, periferna vaskularna oboljenja, priprema za vaskularne procedure, pacijenti koji su operisani zbog karotidne simptomatologije.<\/p>\n

    \"\"Glavne bo\u010dne i zavr\u0161ne grane spolja\u0161nje karotidne arterije, koje razvijaju kolateralne puteve kod okluzije unutra\u0161nje karotidne arterije.<\/em><\/p>\n

    \n

    Asimptomatska segmentna okluzija unutra\u0161nje karotidne arterije. Empirija indikuje karotidnu endarterektomiju jer \u0107e do\u0107i do tromboze distalne ACI.<\/em><\/p>\n<\/div>\n

    \"\"<\/p>\n

    \n

    \u0160um<\/b> <\/b>pri<\/b> <\/b>auskultaciji<\/b> <\/b>karotidnih<\/b> <\/b>arterija<\/b> <\/b>mo\u017ee biti posledica stenoze u pre- delu karotidne bifurkacije ili propagirani kardiogeni \u0161um. \u010ce\u0161\u0107e je nespecifi\u010dan znak razvoja aterosklerotskog oboljenja, pre nego indikator fokalne stenoze. U\u010destalost mo\u017edanog udara je dva puta ve\u0107a, kod pacijenata sa karotidnim \u0161umom od o\u010dekivane za godi\u0161te i pol.<\/p>\n

    Bolesnici<\/b> <\/b>s<\/b> <\/b>perifernom<\/b> <\/b>arterijskom<\/b> <\/b>okluzivnom<\/b> <\/b>bole\u0161\u0107u<\/b> <\/b>imaju general- izovanu arteriosklerozu. Svaki \u010detvrti bolestnik sa ishemijom donjih ekstremiteta ima i stenozu na karotidnim arterijama ve\u0107u od 70%, pri \u010demu 90% pacijenata nema simptome. Staro hirur\u0161ko pravilo ka\u017ee: karotidna arterija ima sli\u010dan stepen ateroskleroti\u010dnog o\u0161te\u0107enja kao i a.femoralis profunda i koronarne arterije u is- tog pacijenta. Dokazana je korelacija stepena karotidne stenoze sa smanjenjem vrednosti Doppler indeksa (ankle-systolic<\/i> <\/i>pressure<\/i> <\/i>index,<\/i> <\/i>API<\/i>). \u0160to je izra\u017eenija periferna okluzivna bolest, to je ve\u0107a incidenca te\u0161ke karotidne stenoze.<\/p>\n

    Pacijenti koji <\/b>se<\/b> <\/b>pripremaju<\/b> <\/b>za<\/b> velike operacije<\/b> <\/b>(op\u0161tehirur\u0161ke, vaskularne,<\/p>\n

    kardohirur\u0161ke, otopedske itd) moraju pro\u0107i kroz Duplex-ultrasonografski skrin- ing.Veliki hirur\u0161ki zahvati dovode do ekstremnih varijacija parametara arterijske (a pogotovo cerebralne) cirkulacije, \u0161to mo\u017ee da dovede do mo\u017edanog udara u pacijenata koji imaju (sub) kriti\u010dnu stenozu na karotidnoj arteriji. Poseban prob- lem su pacijenti sa simultanom karotidnom bole\u0161\u0107u i simptomatskom aneuriz- mom abdominalne aorte. Simultana operacija se mo\u017ee uraditi. Ali, ako je mogu\u0107e prvo treba re\u0161iti problem koji je akutniji. Zna\u010di: prvo se re\u0161ava suspektna ruptura aneurizme abdominalne aorte. Ako je aneurizma asimptomatska, prvo treba otk- loniti asimptomatsku subokluziju karotidne arterije, a potom pacijenta pripremiti za elektivnu resekciju aneurizme.<\/p>\n<\/div>\n

    \"\"<\/p>\n

    \n

    Asimptomatska karotidna stenoza visokostepenim, heterogenim plakom.<\/em><\/p>\n<\/div>\n

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

    \n

    Everziona karotidna endarterektomija<\/em><\/p>\n

    \n

    MSCT angiografija. Visokostepena kalcifikovana ateroskleroti\u010dna stenoza. Asimptomatska stenoza.<\/em><\/em><\/p>\n<\/p>\n<\/div>\n

    \n

    Pacijenti<\/b><\/span> <\/b><\/span>koji<\/b><\/span> <\/b><\/span>ve\u0107<\/b><\/span> <\/b><\/span>imali<\/b><\/span> <\/b><\/span>karotidnu<\/b><\/span> <\/b><\/span>operaciju<\/b><\/span>,<\/span> <\/span>moraju<\/span> <\/span>biti<\/span> <\/span>observirani<\/span> <\/span>zbog<\/span> <\/span>mogu\u0107eg<\/span> <\/span>kontralateralnog<\/span> <\/span>procesa.<\/span> <\/span>European<\/span> <\/span>Carotid<\/span> <\/span>Surgery<\/span> <\/span>Trial<\/span> <\/span>(ECST)<\/span> <\/span>studija,<\/span> <\/span>uklju\u010dila<\/span> <\/span>je<\/span> <\/span>2295<\/span> <\/span>pacijenata<\/span> <\/span>sa<\/span> <\/span>prose\u010dnim<\/span> <\/span>periodom<\/span> <\/span>pra\u0107enja<\/span> <\/span>od<\/span> <\/span>4,5<\/span> <\/span>godina.<\/span> <\/span>Zna\u010dajna<\/span> <\/span>asimptomatska<\/span> <\/span>stenoza<\/span> <\/span>na<\/span> <\/span>kontralateralnoj<\/span> <\/span>karotidnoj<\/span> <\/span>arteriji<\/span> <\/span>(70-99%)<\/span> <\/span>veri<\/span>fi<\/span>kovana<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>6%<\/span> <\/span>pacijenata.<\/span> <\/span><\/sup>U<\/span> <\/span>Severnoj<\/span> <\/span>Americi<\/span> <\/span>i<\/span> <\/span>Kanadi<\/span> <\/span>(Canadian<\/span> <\/span>Stroke<\/span> <\/span>Consortium)<\/span> <\/span>federalni<\/span> <\/span>propisi,<\/span> <\/span>za<\/span> <\/span>sada,<\/span> <\/span>ne<\/span> <\/span>insistiraju<\/span> <\/span>na<\/span> <\/span>obaveznomom<\/span> <\/span>skriningu<\/span> <\/span>asimptomatske<\/span> <\/span>karotidne<\/span> <\/span>bolesti,<\/span> <\/span>u<\/span> <\/span>op\u0161toj<\/span> <\/span>populaciji,<\/span> <\/span>ve\u0107<\/span> <\/span>samo<\/span> <\/span>za<\/span> <\/span>pomenute<\/span> <\/span>u\u017ee<\/span> <\/span>pupulacione<\/span> <\/span>grupe<\/span> <\/span>velikog<\/span> <\/span>rizika<\/span> <\/span>za<\/span> <\/span>karotidnu<\/span> <\/span>stenozu.<\/span> <\/span><\/p>\n

    Indikacije<\/b><\/span> <\/b><\/span>za<\/b><\/span> <\/b><\/span>hirur\u0161ko<\/b><\/span> <\/b><\/span>le\u010denje<\/b><\/span> <\/b><\/span>asimptomatske<\/b><\/span> <\/b><\/span>karotidne<\/b><\/span> <\/b><\/span>stenoze<\/b><\/span><\/p>\n

    Po<\/span> <\/span>American<\/i><\/span> <\/i><\/span>Heart<\/i><\/span> <\/i><\/span>Association<\/i><\/span> <\/i><\/span>Guidelines<\/i><\/span>3<\/span><\/sup> <\/span><\/sup>i<\/span> <\/span>Asymptomatic<\/i><\/span> <\/i><\/span>Carotid<\/i><\/span> <\/i><\/span>Surgery<\/i><\/span> <\/i><\/span>Trial<\/i><\/span> <\/i><\/span>(ACST)<\/i><\/span> <\/span><\/sup>studiji,<\/span> <\/span>hirur\u0161ko<\/span> <\/span>le\u010denje<\/span> <\/span>asimptomatske<\/span> <\/span>karotidne<\/span> <\/span>stenoze<\/span> <\/span>je<\/span> <\/span>indikovano<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>ve\u0107a<\/span> <\/span>od<\/span> <\/span>75%<\/span> <\/span>sa<\/span> <\/span>kontralateralnom<\/span> <\/span>stenozom<\/span> <\/span>od<\/span> <\/span>75<\/span> <\/span>do<\/span> <\/span>100%.<\/span><\/p>\n

    Ako<\/span> <\/span>se<\/span> <\/span>asimptomatska<\/span> <\/span>subokluzija<\/span> <\/span>razvije<\/span> <\/span>u<\/span> <\/span>okluziju,<\/span> <\/span>u<\/span> <\/span>oko<\/span> <\/span>30%<\/span> <\/span>pacijenata<\/span> <\/span>razvi\u0107e<\/span> <\/span>se<\/span> <\/span>masivna<\/span> <\/span>ishemi\u010dna<\/span> <\/span>infarkcija<\/span> <\/span>mozga.<\/span> <\/span>Ostali<\/span> <\/span>bolesnici<\/span> <\/span>\u0107e<\/span> <\/span>imati<\/span> <\/span>manje<\/span> <\/span>neurolo\u0161ke<\/span> <\/span>de<\/span>fi<\/span>cite,<\/span> <\/span>ali<\/span> <\/span>manevarski<\/span> <\/span>prostor<\/span> <\/span>za<\/span> <\/span>kasniju<\/span> <\/span>rekonstrukciju<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>se<\/span> <\/span>gubi<\/span> <\/span>je<\/span> <\/span>trombozira<\/span> <\/span>distalni<\/span> <\/span>segment<\/span> <\/span>u<\/span> <\/span>petroznom<\/span> <\/span>kanalu.<\/span><\/p>\n

    Skener<\/span> <\/span>mozga<\/span> <\/span>(CT)<\/span> <\/span>dijagnostikuje<\/span> <\/span>ishemi\u010dnu<\/span> <\/span>infarkciju<\/span> <\/span>kod<\/span> <\/span>asimptomatskih<\/span> <\/span>karotidnih<\/span> <\/span>stenoza<\/span> <\/span>(oko<\/span> <\/span>75%)<\/span> <\/span>u<\/span> <\/span>oko<\/span> <\/span>70%<\/span> <\/span>pacijenta<\/span> <\/span>(Silent<\/span> <\/span>Brain<\/span> <\/span>Infarction).<\/span> <\/span>Cerebralna<\/span> <\/span>ishemi\u010dka<\/span> <\/span>\u017eari\u0161ta<\/span> <\/span>se<\/span> <\/span>skoro<\/span> <\/span>uvek<\/span> <\/span>nalaze<\/span> <\/span>na<\/span> <\/span>ipsilateralnoj<\/span> <\/span>strani.<\/span><\/p>\n

    Kontralateralna<\/b><\/span> <\/b><\/span>karotidna<\/b><\/span> <\/b><\/span>okluzija<\/b><\/span> <\/b><\/span>i<\/b><\/span> <\/b><\/span>ishemi\u010dki<\/b><\/span> <\/b><\/span>infarkt<\/b><\/span> <\/b><\/span>mozga<\/b><\/span> <\/b><\/span>(CT<\/b><\/span> <\/b><\/span>pozitivan<\/b><\/span> <\/b><\/span>nalaz)<\/b><\/span> <\/b><\/span>u<\/b><\/span> <\/b><\/span>asimptomatskog<\/b><\/span> <\/b><\/span>bolesnika<\/b><\/span> <\/b><\/span>su<\/b><\/span> <\/b><\/span>dodatni<\/b><\/span> <\/b><\/span>razlozi<\/b><\/span> <\/b><\/span>za<\/b><\/span> <\/b><\/span>operaciju<\/b><\/span> <\/b><\/span>pacijenta<\/b><\/span> <\/b><\/span>sa<\/b><\/span> <\/b><\/span>asimptomatskom<\/b><\/span> <\/b><\/span>karotidnom<\/b><\/span> <\/b><\/span>stenozom,<\/b><\/span> <\/b><\/span>pogotovo<\/b><\/span> <\/b><\/span>ako<\/b><\/span> <\/b><\/span>se<\/b><\/span> <\/b><\/span>uskoro<\/b><\/span> <\/b><\/span>planira<\/b><\/span> <\/b><\/span>neka<\/b><\/span> <\/b><\/span>druga<\/b><\/span> <\/b><\/span>velika<\/b><\/span> <\/b><\/span>hirur\u0161ka<\/b><\/span> <\/b><\/span>procedura.<\/b><\/span><\/p>\n

    Asymptomatic<\/i><\/span> <\/i><\/span>Carotid<\/i><\/span> <\/i><\/span>Surgery<\/i><\/span> <\/i><\/span>Trial<\/i><\/span> <\/i><\/span>(ACST),<\/span> <\/span>studija<\/span> <\/span>je<\/span> <\/span>tokom<\/span> <\/span>8<\/span> <\/span>godina<\/span> <\/span>pratila<\/span> <\/span>pacijente<\/span> <\/span>randomizirane<\/span> <\/span>za<\/span> <\/span>medikamentozni<\/span> <\/span>tretman<\/span> <\/span>ili<\/span> <\/span>karotidnu<\/span> <\/span>endarterektomiju.<\/span> <\/span>Institut<\/span> <\/span>za<\/span> <\/span>kardiovaskularne<\/span> <\/span>bolest<\/span> <\/span>\u00abDedinje\u00bb<\/span> <\/span>uklju\u010den<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>ovo<\/span> <\/span>istra\u017eivanje<\/span> <\/span>sa<\/span> <\/span>77<\/span> <\/span>randomiziranih<\/span> <\/span>i<\/span> <\/span>prospektivno<\/span> <\/span>pra\u0107enih<\/span> <\/span>bolesnika.<\/span> <\/span><\/sup>U<\/span> <\/span>toku<\/span> <\/span>je<\/span> <\/span>Asymptomatic<\/i><\/span> <\/i><\/span>Carotid<\/i><\/span> <\/i><\/span>Surgery<\/i><\/span> <\/i><\/span>Trial<\/i><\/span> <\/i><\/span>II <\/i><\/span>(ACST<\/span> <\/span>II),<\/span> <\/span>studija<\/span> u <\/span>kojoj<\/span> <\/span>pratimo<\/span> <\/span>rane<\/span> i<\/span> <\/span>udaljene<\/span> <\/span>rezultate<\/span> <\/span>hirur\u0161kog<\/span> <\/span>i<\/span> <\/span>endovaskularnog<\/span> <\/span>le\u010denja<\/span> <\/span>asimptomatske<\/span> <\/span>karotidne<\/span> <\/span>bolesti.<\/span> <\/span><\/p>\n

    Indikacije<\/b><\/span> <\/b><\/span>za<\/b><\/span> <\/b><\/span>vaskularno<\/b><\/span> <\/b><\/span>ili<\/b><\/span> <\/b><\/span>endovaskularno<\/b><\/span> <\/b><\/span>le\u010denje<\/b><\/span> <\/b><\/span>karotidne<\/b><\/span> <\/b><\/span>bolesti<\/b><\/span> <\/b><\/span>se<\/b><\/span> <\/b><\/span>postavljaju<\/b><\/span> <\/b><\/span>na<\/b><\/span> <\/b><\/span>bazi:<\/b><\/span><\/p>\n

      \n
    • Stepen<\/span> <\/span>karotidne<\/span> <\/span>stenoze<\/span><\/li>\n
    • Komorbiditet<\/span><\/li>\n
    • V<\/span>askularn<\/span>e<\/span> <\/span>i<\/span> <\/span>lokaln<\/span>e<\/span> <\/span>anatomsk<\/span>e<\/span> <\/span>karakteristik<\/span>e<\/span><\/li>\n
    • Morfologija<\/span> <\/span>karotidnog<\/span> <\/span>plaka<\/span><\/li>\n<\/ul>\n

      Hirur\u0161ko<\/b><\/span> <\/b><\/span>le\u010denje<\/b><\/span> <\/b><\/span>asimptomatske<\/b><\/span> <\/b><\/span>karotidne<\/b><\/span> <\/b><\/span>stenoze<\/b><\/span> <\/b><\/span>ve\u0107e<\/b><\/span> <\/b><\/span>od<\/b><\/span> <\/b><\/span>75%<\/b><\/span> <\/b><\/span>je<\/b><\/span> <\/b><\/span>in-<\/b><\/span> <\/b><\/span>dikovano<\/b><\/span> <\/b><\/span>ako<\/b><\/span> <\/b><\/span>je<\/b><\/span> <\/b><\/span>o\u010dekivano<\/b><\/span> <\/b><\/span>trajanje<\/b><\/span> <\/b><\/span>\u017eivota<\/b><\/span> <\/b><\/span>dovoljno<\/b><\/span> <\/b><\/span>da<\/b><\/span> <\/b><\/span>opravda<\/b><\/span> <\/b><\/span>rizik,<\/b><\/span> <\/b><\/span>kon-<\/b><\/span> <\/b><\/span>tralateralna<\/b><\/span> <\/b><\/span>karotidna<\/b><\/span> <\/b><\/span>stenoza<\/b><\/span> <\/b><\/span>zna\u010dajna<\/b><\/span> <\/b><\/span>ili<\/b><\/span> <\/b><\/span>ako<\/b><\/span> <\/b><\/span>je<\/b><\/span> <\/b><\/span>ipsilateralno<\/b><\/span> <\/b><\/span>CT<\/b><\/span> <\/b><\/span>nalaz<\/b><\/span> <\/b><\/span>mozga pozitivan (Silent Brain Infarction).<\/b><\/p>\n

      Karotidna<\/b> <\/b>endarterektomija<\/b> <\/b>mo\u017ee<\/b> <\/b>biti<\/b> <\/b>preporu\u010dena<\/b> <\/b>kod<\/b> <\/b>asimptomatski-<\/b> <\/b>hpacijenata<\/b> <\/b>ispod<\/b> <\/b>75<\/b> <\/b>godina<\/b> <\/b>starosti<\/b> <\/b>sa<\/b> <\/b>karotidnom<\/b> <\/b>stenozom<\/b> <\/b>od<\/b> <\/b>70%<\/b> <\/b>do<\/b> <\/b>99%<\/b>, ukoliko je operativni rizik manji od 3%.<\/p>\n

      U asimptomatskih pacijenata \u017eenskog pola sa karotidnom stenozom korist od endarterektomije je zna\u010dajno manja nego kod mu\u0161karaca.<\/p>\n

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

      Angioplastiku<\/b> <\/b>i<\/b> <\/b>endarterektomiju<\/b> <\/b>karotidnih<\/b> <\/b>arterija<\/b> <\/b>ne<\/b> <\/b>bi<\/b> <\/b>trebalo<\/b> <\/b>pred-<\/b> <\/b>lagati<\/b> <\/b>asimptomatskim<\/b> <\/b>visoko<\/b> <\/b>rizi\u010dnim<\/b> <\/b>pacijentima<\/b> <\/b>ukoliko<\/b> <\/b>je<\/b> <\/b>stopa<\/b> <\/b>peri- proceduralih<\/b> <\/b>komplikacija<\/b> <\/b>>3%.<\/b> <\/b>Medikamentozna terapija je u tom slu\u010daju sigurnija opcija.<\/p>\n

      \n

      Prospektivna, randomizirana, multicentri\u010dna
      studija asimptomatske karotidne bolesti
      (Asymptomatic Carotid Surgery Trial \u2013 ACST II)<\/em><\/p>\n<\/p>\n<\/div>\n


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

      INDIKACIJE ZA ENDARTEREKTOMIJU KOD ASIMPTOMATSKE KAROTIDNE STENOZE All cases are unique and very similar to others. T.S. Eliot Experience dulls the edges of all our dogmas. Gilbert Murray Asimptomatska stenoza podrazumeva prisustvo stenoti\u010dnih lezija na karotidnoj bifurkaciji, u bolesnika koji jo\u0161 uvek nije imao simptome mo\u017edane ishemije. Te\u0161ke ateroskleroti\u010dne lezije karotidnog sliva mogu da ostanu […]<\/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-2872","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n9. 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