{"id":3864,"date":"2023-02-13T14:34:09","date_gmt":"2023-02-13T14:34:09","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=3864"},"modified":"2023-02-23T17:27:51","modified_gmt":"2023-02-23T17:27:51","slug":"14-visoki-pristup-karotidnoj-arteriji","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=3864","title":{"rendered":"14. \u201cVISOKI PRISTUP\u201d KAROTIDNOJ ARTERIJI"},"content":{"rendered":"

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

<\/p>\n

\u201cVISOKI PRISTUP\u201d KAROTIDNOJ ARTERIJI<\/h1>\n

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

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Goo<\/i>d<\/i> <\/i>judgemen<\/i>t<\/i> <\/i>need<\/i>s<\/i> <\/i>experience<\/i>.<\/i> <\/i>Howeve<\/i>r<\/i>,<\/i> <\/i>experienc<\/i>e<\/i> <\/i>need<\/i>s<\/i> <\/i>t<\/i>o<\/i> <\/i>se<\/i>e <\/i>lendscapes<\/i> <\/i>outside<\/i> <\/i>of<\/i> <\/i>security.<\/i><\/p>\n

Paul Valery<\/em><\/p>\n<\/div>\n

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\u201cVisoki<\/b><\/span> <\/b><\/span>pristup\u201d<\/b><\/span> <\/b><\/span>karotidnoj<\/b><\/span> <\/b><\/span>arteriji<\/b><\/span> <\/b><\/span>(<\/span>A.carotis<\/i><\/span> <\/i><\/span>interna<\/i><\/span> <\/i><\/span>distalis<\/i><\/span>)<\/span> <\/span>eksponira<\/span> <\/span>unutra\u0161nju<\/span> <\/span>karotidnu<\/span> <\/span>arteriju<\/span> <\/span>iznad<\/span> <\/span>linije<\/span> <\/span>koja<\/span> <\/span>povezuje<\/span> <\/span>vrh<\/span> <\/span>mastoidnog<\/span> <\/span>procesusa<\/span> <\/span>i<\/span> <\/span>angulus<\/i><\/span>-a<\/span> <\/span>mandibulae<\/i><\/span>.<\/span><\/p>\n

Ova<\/span> <\/span>linija<\/span> <\/span>odgovara<\/span> <\/span>projekciji<\/span> <\/span>gornje<\/span> <\/span>ivice<\/span> <\/span>tela<\/span> <\/span>drugog<\/span> <\/span>cervikalnog<\/span> <\/span>(C2)<\/span> <\/span>pr\u0161lje-<\/span> <\/span>na.<\/span> <\/span>Deo<\/span> <\/span>arterije<\/span> <\/span>ispod<\/span> <\/span>ovog<\/span> <\/span>nivoa<\/span> <\/span>pristupa\u010dan<\/span> <\/span>je<\/span> <\/span>standardnim<\/span> <\/span>tehnikama<\/span> <\/span>prepa-<\/span> <\/span>risanja.<\/span> <\/span>Deo<\/span> <\/span>arterije<\/span> <\/span>iznad<\/span> <\/span>ove<\/span> <\/span>linije<\/span> <\/span>dugo<\/span> <\/span>je<\/span> <\/span>smatran<\/span> <\/span>hirur\u0161ki<\/span> <\/span>nepristupa\u010dnim.<\/span> <\/span><\/p>\n

Visoko<\/span> <\/span>preparisanje<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>spada<\/span> <\/span>u<\/span> <\/span>najizazovnije<\/span> <\/span>i<\/span> <\/span>tehni\u010dki<\/span> <\/span>najdelikatnije<\/span> <\/span>pristupe<\/span> <\/span>u<\/span> <\/span>vaskularnoj<\/span> <\/span>hirurgiji.<\/span><\/p>\n

Indikacije<\/b><\/span> <\/b><\/span>za<\/span> <\/span>pristup<\/span> <\/span>unutra\u0161njoj<\/span> <\/span>karotidnoj<\/span> <\/span>arteriji<\/span> <\/span>na<\/span> <\/span>bazi<\/span> <\/span>lobanje<\/span> <\/span>postoje<\/span> <\/span>u<\/span> <\/span>slu\u010daju<\/span> <\/span>vrlo<\/span> <\/span>visokih<\/span> <\/span>arterioskleroti\u010dnih,<\/span> <\/span>fi<\/span>bromuskularnih<\/span> <\/span>(degenerativnih)<\/span> <\/span>lezija<\/span> <\/span>i<\/span> <\/span>aneurizmi,<\/span> <\/span>dok<\/span> <\/span>su<\/span> <\/span>povrede<\/span> <\/span>ovog<\/span> <\/span>segmenta<\/span> <\/span>ne\u0161to<\/span> <\/span>re\u0111e,<\/span> <\/span>ali<\/span> <\/span>dramati\u010dne.<\/span><\/p>\n

Prilikom<\/span> <\/span>izbora<\/span> <\/span>tipa<\/span> <\/span>visokog<\/span> <\/span>pristupa<\/span> <\/span>moramo<\/span> <\/span>se<\/span> <\/span>razumno<\/span> <\/span>suo\u010diti<\/span> <\/span>sa<\/span> <\/span>dilemom:<\/span> <\/span>ukoliko<\/span> <\/span>je<\/span> <\/span>na\u0161a<\/span> <\/span>disekcija<\/span> <\/span>ekstenzivnija<\/span> <\/span>ekspozicija<\/span> <\/span>arterije<\/span> <\/span>\u0107e<\/span> <\/span>biti<\/span> <\/span>bolja,<\/span> <\/span>ali<\/span> <\/span>i<\/span> <\/span>mogu\u0107<\/span>e<\/span> <\/span>postoperativn<\/span>e<\/span> <\/span>posledic<\/span>e<\/span> <\/span>\u0107<\/span>e<\/span> <\/span>bit<\/span>i<\/span> <\/span>ve\u0107e<\/span>.<\/span> <\/span><\/p>\n

V<\/i><\/span>elik<\/i><\/span>e<\/i><\/span> <\/i><\/span>\u017ertv<\/i><\/span>e<\/i><\/span> <\/i><\/span>n<\/i><\/span>e<\/i><\/span> <\/i><\/span>moraj<\/i><\/span>u<\/i><\/span> <\/i><\/span>uve<\/i><\/span>k<\/i><\/span> <\/i><\/span>d<\/i><\/span>a<\/i><\/span> <\/i><\/span>daju<\/i><\/span> <\/i><\/span>velike<\/i><\/span> <\/i><\/span>rezultate<\/i><\/span>.<\/span> <\/span>Zato<\/span> <\/span>\u0107e<\/span> <\/span>opis<\/span> <\/span>ovih<\/span> <\/span>metoda<\/span> <\/span>i\u0107i<\/span> <\/span>od<\/span> <\/span>najbezazlanijih<\/span> <\/span>(i<\/span> <\/span>najmaje<\/span> <\/span>mutilantnih)<\/span> <\/span>ka<\/span> <\/span>komplikovanijim,<\/span> <\/span>korak<\/span> <\/span>po<\/span> <\/span>korak.<\/span><\/p>\n

Razlikujemo<\/span><\/p>\n

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  • Anterolateralne<\/b><\/span> <\/b><\/span>hirur\u0161ke<\/b><\/span> <\/b><\/span>pristupe<\/b><\/span> <\/b><\/span>sa<\/span> <\/span>mandibularnom<\/span> <\/span>subluksacijom<\/span> <\/span>i<\/span> <\/span>resekcijom<\/span> <\/span>mi\u0161i\u0107a<\/span> <\/span>(<\/span>mandibularne<\/b><\/span> <\/b><\/span>procedure<\/b><\/span>)<\/span> <\/span>i<\/span><\/li>\n
  • Posterolateralne<\/b><\/span> <\/b><\/span>pristupe<\/b><\/span>,<\/span> <\/span>sa<\/span> <\/span>resekcijom<\/span> <\/span>mi\u0161i\u0107a,<\/span> <\/span>uz<\/span> <\/span>ili<\/span> <\/span>bez<\/span> <\/span>mastoidektomije<\/span> <\/span>(<\/span>mastoidne<\/b><\/span> <\/b><\/span>procedure<\/b><\/span>).<\/span><\/li>\n<\/ul>\n

    Resekcija<\/b><\/span> <\/b><\/span>zadnjeg<\/b><\/span> <\/b><\/span>dela<\/b><\/span> <\/b><\/span>digastri\u010dnog<\/b><\/span> <\/b><\/span>mi\u0161i\u0107a<\/b><\/span>.<\/span> <\/span>Pacijent<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>standardnom<\/span> <\/span>polo\u017eaju.<\/span> <\/span>Sterilno<\/span> <\/span>garniranje<\/span> <\/span>u\u010dinjeno<\/span> <\/span>je<\/span> <\/span>tako<\/span> <\/span>da<\/span> <\/span>predeo<\/span> <\/span>oko<\/span> <\/span>u\u0161ne<\/span> <\/span>\u0161koljke<\/span> <\/span>bude<\/span> <\/span>slobodan.<\/span> <\/span>Nakon<\/span> <\/span>klasi\u010dnog<\/span> <\/span>preparisanja<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>idu\u0107i<\/span> <\/span>put<\/span> <\/span>distalno<\/span> <\/span>nailazimo<\/span> <\/span>na<\/span> <\/span>digastri\u010dni<\/span> <\/span>mi\u0161i\u0107.<\/span> <\/span>Njegov<\/span> <\/span>zadnji<\/span> <\/span>trbuh<\/span> <\/span>sna\u017eno<\/span> <\/span>ekartiramo<\/span> <\/span>distalno<\/span> <\/span>ili<\/span> <\/span>reseciramo.<\/span> <\/span>Na<\/span> <\/span>taj<\/span> <\/span>na\u010din<\/span> <\/span>mo\u017eemo<\/span> <\/span>da<\/span> <\/span>pratimo<\/span> <\/span>unutra\u0161nju<\/span> <\/span>karotidnu<\/span> <\/span>arteriju<\/span> <\/span>do<\/span> <\/span>nivoa<\/span> <\/span>prvog<\/span> <\/span>intertransverzalnog<\/span> <\/span>prostora.<\/span> <\/span>To<\/span> <\/span>zna\u010di<\/span> <\/span>da<\/span> <\/span>smo<\/span> <\/span>prikazali<\/span> <\/span>jo\u0161<\/span> <\/span>oko<\/span> <\/span>1,2cm<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span> <\/span>Ovo,<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>dovoljno<\/span> <\/span>za<\/span> <\/span>izvo\u0111enje<\/span> <\/span>rekonstrukcije<\/span> <\/span>ili<\/span> je<\/span> <\/span>samo<\/span> <\/span>uvod<\/span> <\/span>u <\/span>dalju<\/span> <\/span>anterolateralnu<\/span> <\/span>disekciju<\/span> <\/span>put<\/span> <\/span>distalno.<\/span> Sa<\/span> <\/span>ekspanzijom<\/span> <\/span>disekcije<\/span> <\/span>na\u0161a<\/span> <\/span>opreznost<\/span> <\/span>u<\/span> <\/span>pogledu<\/span> <\/span>lezija<\/span> <\/span>okolnih<\/span> <\/span>\u017eivaca<\/span> <\/span>raste.<\/span><\/p>\n<\/div>\n

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    Visoki prednji pristup distalnoj cervikalnoj unutra\u0161njoj karotidnoj arteriji. Elevacija i\/ <\/em>ili resekcija digastri\u010dnog mi\u0161i\u0107a bez lediranja glosofaringealnog \u017eivca.<\/em><\/p>\n

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

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    Kranijalni \u017eivci koji mogu biti ledirani prilikom visokog preparisanja unutra\u0161nje karotidne arterije. Nije prikazan n. hypoglossus koji je ne\u0161to ni\u017ee i n. facialis koji je ne\u0161to vi\u0161e.<\/em><\/p>\n<\/div>\n

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    Prednja<\/b> <\/b>subliksacija<\/b> <\/b>mandibule.<\/b> <\/b>Fiziolo\u0161ka bilateralna prednja mandibularna subluksacija do nivoa artikularne eminencije podrazumeva pomeranje mandibule za 2 do 3cm napred. Ovaj grif pro\u0161iruje operativno polje toliko da se disekcija karotidne arterije mo\u017ee nastaviti za 1-2cm distalno,to zna\u010di do projekcije gornjeg dela prvog cervikalnog (C1) pr\u0161ljena. Patolo\u0161ku dislokaciju mandibule sa prodiranjem kondilusa mandibule u infratemporalnu jamu treba izbegavati jer daje postoperativno jak bolni sindrom sa disfunkcijom zgloba.<\/p>\n<\/div>\n

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    Nakon standardnog preparisanja karotidne arterije i postavljanja \u017ei\u010danih fiksatora mandibula se manuelno subluksira (10-15mm napred). \u017di\u010dani fiksatori koji<\/span> <\/span>su<\/span> <\/span>prethodno<\/span> <\/span>postavljeni<\/span> <\/span>cirkummandibularno<\/span> <\/span>i<\/span> <\/span>transnazalno<\/span> <\/span>slu\u017ee<\/span> <\/span>za<\/span> <\/span>u\u010dvr\u0161\u0107ivanje<\/span> <\/span>mandibule<\/span> <\/span>u<\/span> <\/span>ovom<\/span> <\/span>polo\u017eaju.<\/span> <\/span>Prednju<\/span> <\/span>subluksaciju<\/span> <\/span>kondila<\/span> <\/span>mandibule<\/span> <\/span>odr\u017eavamo<\/span> <\/span>do<\/span> <\/span>kraja<\/span> <\/span>rekonstrukcije<\/span> <\/span>subperiostalnom<\/span> <\/span>fi<\/span>ksacijom<\/span> <\/span>(\u017eica).<\/span><\/p>\n

    Moramo da izbegnamo patolo\u0161ku dislokaciju mandibularnog kondila u infratemporalnu jamu. Mandibularni kondilus mora biti zadr\u017ean u visini artikularne eminencije, koja se nalazi medijalno od glenoidalne jame. Tako se zna\u010dajno pro\u0161iruje pregled nad distalnim delom karotidne arterije. O\u0161tri gornji ugao na\u0161eg operativnog polja se pretvara u pravougaonik.<\/p>\n<\/div>\n

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    Visoki cervikalni pristup distalnom delu unutra\u0161nje karotidne arterije: Disekcija je ograni\u010dena o\u0161trim vrhom trougla \u010diji vrh je na bazi lobanje (A), Orotrahealna intubacija (B), Prednja subluksacija mandibule zna\u010dajno pro\u0161iruje pristup (C), Nazotrahealna intubacija u kombinaciji sa prednjom subluksacijom mandibule omogu\u0107uje jo\u0161 \u0161iru ekspoziciju u bazu lobanje (D).<\/em><\/p>\n<\/div>\n

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    Subluksaciju mandibule<\/strong> mo\u017eemo, ako je neohodno, kombinovati sa resekcijom digastri\u010dnog ili stiloidnih mi\u0161i\u0107a. Nakon zavr\u0161etka arterijske rekonstrukcije \u017ei\u010dani fiksatori se odstranjuju. Mandibula se vra\u0107a u normalnu poziciju. Postoperativno pacijent je sutradan sposoban za uobi\u010dajenu ishranu, a postoperativni znaci disfunkcije temporomandibularnog zgloba (malokluzija) i bolni sindrom se retko registruju.<\/p>\n<\/div>\n

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    Anatomija prednje subluksacije mandibule: Mandibularni kondilus se subluksira preko artikularne eminencije, ali se ne dozvoljava njegova potpuna dislokacija u infratemporalnu jamu. Ovaj manevar pretvara o\u0161trougaoni prostor pristupa distalnoj karotidnoj arteriji u pravougaoni.<\/em><\/p>\n

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

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    Stiloidektomija<\/b> <\/b>sa <\/b>resekcijom<\/b> <\/b>stiloidnih<\/b> <\/b>mi\u0161i\u0107a.<\/b> <\/b>Ako je neizbe\u017ean ekstenzivniji pristup od onog koji nam omogu\u0107uje resekcija digastri\u010dnog mi\u0161i\u0107a sa blagom mandibularnom subluksacijom, mo\u017eemo da se odlu\u010dimo za resekciju stiloidnog nastavka (processus<\/i> <\/i>styloideus<\/i>) sa mi\u0161i\u0107ima koji se na njemu pripajaju. Ova metoda, takodje, spada u prednje pristupe.<\/p>\n

    Prednji visoki pristup karotidnoj arteriji sa resekcijom stiloidne mi\u0161i\u0107ne grupe (m.styloglossus,<\/i> <\/i>m.stylopharyngeus,<\/i> <\/i>m.stylohyoideus<\/i>). Posebna pa\u017enja se mora obratiti na glosofaringealni \u017eivac. Ako resekcija mi\u0161i\u0107nih pripoja nije dovoljna, mora se odstraniti i sam stiloidni nastavak.<\/p>\n

    Resekcija stiloidnog produ\u017eetka i odgovaraju\u0107ih mi\u0161i\u0107a nam omugu\u0107ava da dopremo do nivoa gornje ivice prvog vratnog pr\u0161ljena (C1). To zna\u010di 4-5mm vi\u0161e u odnosu na prednji pristup sa resekcijom digastri\u010dnog mi\u0161i\u0107a i subluksacijim mandibule. Dodatni rizik ove metode sa ekstenzivnom mi\u0161i\u0107nom disekcijom nije veliki. Potencijalno najte\u017ee su lezije facijalnog \u017eivca.<\/p>\n

    U velikoj ve\u0107ini elektivnih hirur\u0161kih zahvata dovoljna je resekcija digastri\u010dnog mi\u0161i\u0107a sa stiloidektomijom. Mandibularna subluksacija je re\u0111e potrebna. Ove metode anterolateralnog pristupa su pogodne jer ne zahtevaju puno vremena, \u0161to je va\u017eno za slu\u010dajeve akutne traume sa krvarenjem.<\/p>\n

    Mandibularna<\/b> <\/b>osteotomija.<\/b> <\/b>Posle resekcije digastri\u010dnog i stiloidnih mi\u0161i\u0107a prese\u010de se vertikalni ramus<\/i> <\/i>mandibulae<\/i> <\/i>izmedju koronoidnog i kondiloidnog procesusa. Presecanje vertikalnog ramusa mandibule izvodi se subperiostalnom resekcijom. Pri tome moramo sa\u010duvati donju alveolarnu arteriju i nerv. Temporomandibularni zglobni segmant madibule se rotira put spolja da bi smo pri\u0161li distalnoj unutra\u0161njoj karotidnoj arteriji. Nakon rekonstrukcije segmenti se reponiraju i fiksiraju \u017eicom sa ili bez intermaksilarne fiksacije.<\/p>\n<\/div>\n

    \n

    Visoki pristup unutra\u0161njoj karotidnoj arteriji: Pravac incizije na ko\u017ei i ekspozicija glosofaringealnog nerva ispod parotidne \u017elezde sa resekcijom digastri\u010dnog i stilohioidnog mi\u0161i\u0107a.<\/em><\/p>\n<\/div>\n

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    Resekcija mandibule za visoki pristup karotidnoj arteriji: oslobadjanje ramus-a mandibula-e od mi\u0161i\u0107nih pripoja i parotidne \u017elezde (A) i Uzdu\u017ena resekcija ramus-a mandibula-e uz elevaciju mandibularnog kondilusa (B).<\/em><\/p>\n<\/p>\n<\/div>\n

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    Visoki pristup unutra\u0161njoj karotidnoj <\/em>arteriji. Resekcija digastri\u010dnog mi\u0161i\u0107a sa <\/em>resekcijom ramus-a mandibula-e i rotacijom ko\u0161tanih fragmenata.<\/em><\/p>\n<\/div>\n

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    Pomeranjem prednjeg segmenta mandibule put napred, posle osteotomije angulus<\/i>-a mandibulae<\/i> <\/i>pru\u017ea ne\u0161to \u0161iri pristup. Na primer za anastomozu na visokom distalnom segmentu karotidne arterije, na oko 1cm ispod baze lobanje, u slu\u010daju traume sa te\u0161kim krvarenjem. Omogu\u0107ava ekspoziciju unutra\u0161nje karotidne arterije do iznad nivoa prvog ki\u010dmenog pr\u0161ljena. Vrlo retko nam je potreban vi\u0161i pristup.<\/p>\n

    Mandibularna osteotomija mo\u017ee da dovede do intraoralne kontaminacije rane i lezije facijalnog \u017eivca, pa je treba izbegavati, osim iz vitalnih indikacija .<\/p>\n

    Posterolateralni<\/b> <\/b>pristup<\/b> <\/b>sa<\/b> <\/b>resekcijom<\/b> <\/b>mastoidnog<\/b> <\/b>procesusa<\/b> <\/b>je potreban za prikaz poslednjih milimetara cervikane karotidne arterije, kao i po\u010detnog dela njenog intrapetroznog segmenta. Facijalni, glosofaringealni i hipoglosni \u017eivac treba pa\u017eljivo \u010duvati.<\/p>\n

    Zadnji pristup sa resekcijom mastoidnog procesusa zahteva identifikaciju sedmog cervikalnog \u017eivca i retrakciju parotidne \u017eljezde put napred i gore. Podrazumeva se resekcija digastri\u010dnog mi\u0161i\u0107a i stiloidnog produ\u017eetka. Problem je \u0161to mastoidektomija \u010desto ledira slu\u0161ne ko\u0161\u010dica, i mo\u017ee dovesti do poreme\u0107aja sluha. Lezije okolnih nerava se moraju o\u010dekivati u oko 25% pacijenata.<\/p>\n

    Ovaj pristup, osim \u0161to je rizi\u010dan, zahteva i puno vremena, pa nije pogodan \u010dak ni za urgentnu traumatologiju gde se retko mora zaustaviti krvarenje iz najvi\u0161eg dela karotidne arterije.<\/p>\n<\/div>\n

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    Visoki distalni prilaz unutra\u0161njoj karotidnoj arteriji. Parcijalna resekcija processus-a mastoideus-a sa mobilizacijom facijalnog nerva.<\/em><\/p>\n<\/div>\n


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

    \u201cVISOKI PRISTUP\u201d KAROTIDNOJ ARTERIJI Good judgement needs experience. However, experience needs to see lendscapes outside of security. Paul Valery \u201cVisoki pristup\u201d karotidnoj arteriji (A.carotis interna distalis) eksponira unutra\u0161nju karotidnu arteriju iznad linije koja povezuje vrh mastoidnog procesusa i angulus-a mandibulae. Ova linija odgovara projekciji gornje ivice tela drugog cervikalnog (C2) pr\u0161lje- na. Deo arterije ispod […]<\/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-3864","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n14. \u201cVISOKI PRISTUP\u201d KAROTIDNOJ ARTERIJI - KAROTIDNA HIRURGIJA<\/title>\n<meta name=\"description\" content=\"\u201cVisoki pristup\u201d karotidnoj arteriji (A.carotis interna distalis) eksponira unutra\u0161nju karotidnu arteriju iznad linije koja povezuje vrh mastoidnog procesusa i angulus-a mandibulae.\" \/>\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=3864\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"14. \u201cVISOKI PRISTUP\u201d KAROTIDNOJ ARTERIJI - 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