{"id":4253,"date":"2023-02-15T11:37:48","date_gmt":"2023-02-15T11:37:48","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=4253"},"modified":"2023-02-24T09:22:03","modified_gmt":"2023-02-24T09:22:03","slug":"17-2-lecenje-arterijskih-povreda","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=4253","title":{"rendered":"17.2. LE\u010cENJE ARTERIJSKIH POVREDA"},"content":{"rendered":"

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

<\/p>\n

POVREDE ARTERIJA KOJE ISHRANJUJU MOZAK<\/h1>\n

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

\n

17.2. LE\u010cENJE ARTERIJSKIH POVREDA<\/h2>\n<\/h1>\n
\n

LE\u010cENJE ARTERIJSKIH POVREDA<\/h3>\n

Neposredni cilj je zaustavljanje krvarenja, nadoknada volumena, prevencija \u0161oka i spa\u0161avanje \u017eivota, a potom rekonstrukcija povre\u0111ene arterije uz o\u010duvanje funkcije mozga i\/ili gornjeg ekstremiteta.<\/p>\n

Zustavljanje krvarenja je urgentna mera. Mo\u017ee biti:
(a) privremeno ili
(b) definitivno.<\/p>\n

Privremeno zaustavljanje krvarenja je mogu\u0107e ako se radi o magistralnim arterijama ekstremiteta; (1) Digitalnom kompresijom na arteriju ili (2) asepti\u010dnim kompresivnim zavojem na mestu krvarenja. Privremenu hemostazu klemovanjem ledirane arterije peanom ili provizornim ligaturama treba izbegavati. Nasumi\u010dno<\/p>\n

klemovanje dovodi do lezija okolnih neuro-vaskularnih struktura. Osim toga, klemovani arterijski segment postaje neupotrebljiv za kasniju arterijsku rekonstrukciju. Ako lekar nije siguran da mo\u017ee da re\u0161i povredu eksploraciju treba prepustiti vaskularnom hirurgu. Vene vrata nalaze se izme\u0111u fascija koje u slu\u010daju povreda odr\u017eavaju zjap vene, a podpritisak u proksimalnom kraju omogu\u0107ava aspiraciju vazduha i mogu\u0107nost nastajanje vazdu\u0161ne embolije.<\/p>\n

Ako postoji nagove\u0161taj kompresije na respiratorne puteve, pacijenta treba odmah intubirati i staviti na arterficijelnu ventilaciju. Kasnije endotrahealna intubacija mo\u017ee postati nemogu\u0107a zbog naglog rasta hematoma. Bitno je da se bolesnik \u0161to pre transportuje do centra gde se mo\u017ee na\u010diniti revaskularizacija. Ishemija mozga ne sme trajati vi\u0161e od 2 sata. Ruka mo\u017ee tolerisati ishemiju oko 6 sati. Ako je ishemije trajala du\u017ee nakon revaskularizacije se mogu javiti ozbiljne komplikacije; ispiranje velike koli\u010dine metabolita mioglobina i kiselih produkata u cirkulaciju (tourniquet<\/i> <\/i>shock<\/i>) sa mogu\u0107om posledi\u010dnom renalnom insuficijencijom. \u0160to je ishemija du\u017ee trajala op\u0161te posledice kasne revaskularizacije i lokalni postrevaskularizacioni sindrom \u0107e biti te\u017ei.<\/p>\n

Neophodno je da se odmah zapo\u010dne sa volumenskom supstitucijom krvi (plazma ekspanderi) intravenskim putem, antitetanusna za\u0161tita i po\u010detna doza antibiotika. U me\u0111uvremenu bolesnik ve\u0107 mora biti na putu ka vaskularnom centru. Le\u010denje politraumatizovanog bolesnika podrazumeva uigranu saradnju anesteziologa sa hirur\u0161kim timom (traumatolog, vaskularni hirurg, neurohirurg, itd.).<\/p>\n

Uspostavljanje<\/span> <\/span>i<\/span> <\/span>odr\u017eavanje<\/span> <\/span>vitalnih<\/span> <\/span>funkcija<\/span> <\/span>je<\/span> <\/span>primarni<\/span> <\/span>zadatak.<\/span> <\/span>Kontrolisana<\/span> <\/span>sr\u010dana<\/span> <\/span>i<\/span> <\/span>respiratorna<\/span> <\/span>funkcija<\/span> <\/span>i<\/span> <\/span>spre\u010davanje<\/span> <\/span>\u0161oka<\/span> <\/span>imaju<\/span> <\/span>prioritet.<\/span><\/p>\n

Zbrinjavanje<\/span> <\/span>povreda<\/span> <\/span>karotidnih<\/span> <\/span>i<\/span> <\/span>bronhopulmonalnih<\/span> <\/span>arterija,<\/span> <\/span>koje<\/span> <\/span>mogu<\/span> <\/span>dovesti<\/span> <\/span>do<\/span> <\/span>ireverzibilnih<\/span> <\/span>cerebralnih<\/span> <\/span>i<\/span> <\/span>kardijalnih<\/span> <\/span>o\u0161te\u0107enja<\/span> <\/span>je<\/span> <\/span>hirur\u0161ki<\/span> <\/span>prioritet.<\/span> <\/span>Potom<\/span> <\/span>dolaze<\/span> <\/span>na<\/span> <\/span>red<\/span> <\/span>povrede<\/span> <\/span>krvnih<\/span> <\/span>sudova<\/span> <\/span>ekstremiteta,<\/span> <\/span>\u010dije<\/span> <\/span>se<\/span> <\/span>ra\u0161avanje<\/span> <\/span>mo\u017ee<\/span> <\/span>odlo\u017eiti<\/span> <\/span>za<\/span> <\/span>4-6<\/span> <\/span>sati.<\/span><\/p>\n

Eksploraciju<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>treba<\/span> <\/span>uraditi<\/span> <\/span>i<\/span> <\/span>kod<\/span> <\/span>povreda<\/span> <\/span>u<\/span> <\/span>kojih<\/span> <\/span>je<\/span> <\/span>do\u0161lo<\/span> <\/span>do<\/span> <\/span>privremenog<\/span> <\/span>prestanka<\/span> <\/span>krvarenja<\/span> <\/span>zbog<\/span> <\/span>za\u010depljenja<\/span> <\/span>trombom,<\/span> <\/span>radi<\/span> <\/span>otkrivanja<\/span> <\/span>kontuzija<\/span> <\/span>krvnog<\/span> <\/span>suda<\/span> <\/span>koje<\/span> <\/span>u<\/span> <\/span>kasnijem<\/span> <\/span>toku<\/span> <\/span>mogu<\/span> <\/span>dovesti<\/span> <\/span>do<\/span> <\/span>disekcije,<\/span> <\/span>okluzije,<\/span> <\/span>rupture,<\/span> <\/span>krvarenja<\/span> <\/span>ili<\/span> <\/span>pojave<\/span> <\/span>la\u017ene<\/span> <\/span>aneurizme.<\/span> <\/span>Eksploracija<\/span> <\/span>se<\/span> <\/span>vr\u0161i<\/span> <\/span>u<\/span> <\/span>op\u0161toj<\/span> <\/span>anesteziji.<\/span> <\/span>Odstrani<\/span> <\/span>se<\/span> <\/span>hematom<\/span> <\/span>i<\/span> <\/span>eventualno<\/span> <\/span>prisutna<\/span> <\/span>strana<\/span> <\/span>tela.<\/span> <\/span>Ako<\/span> <\/span>je<\/span> <\/span>sumnjiva<\/span> <\/span>povreda<\/span> <\/span>unutra\u0161neg<\/span> <\/span>zida<\/span> <\/span>aterije<\/span> <\/span>treba<\/span> <\/span>je<\/span> <\/span>klemovati<\/span> <\/span>i<\/span> <\/span>otvoriti.<\/span><\/p>\n

Ako<\/span> <\/span>je<\/span> <\/span>lezija<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>suvi\u0161e<\/span> <\/span>visoko<\/span> <\/span>(baza<\/span> <\/span>lobanje)<\/span> <\/span>distalno<\/span> <\/span>klemovanje<\/span> <\/span>nije<\/span> <\/span>neophodno,<\/span> <\/span>i<\/span> <\/span>mo\u017eemo<\/span> <\/span>ga<\/span> <\/span>zameniti<\/span> <\/span>intraluminalnim<\/span> <\/span>shunt<\/i><\/span>-om<\/span> <\/span>sa<\/span> <\/span>okluzivnim<\/span> <\/span>balonom.<\/span> <\/span>Pruitt-Inahara<\/span> <\/span>intraluminalni<\/span> <\/span>shunt<\/span> <\/span>je<\/span> <\/span>najzgodniji<\/span> <\/span>jer<\/span> <\/span>istovremeno<\/span> <\/span>odr\u017eava<\/span> <\/span>cerebralnu<\/span> <\/span>cirkulaciju<\/span> <\/span>tokom<\/span> <\/span>rekonstrukcije<\/span> <\/span>i<\/span> <\/span>kontroli\u0161e<\/span> <\/span>krvarenj<\/span>e<\/span> <\/span>i<\/span>z<\/span> <\/span>proksimalno<\/span>g<\/span> <\/span>i<\/span> <\/span>di<\/span>s<\/span>talno<\/span>g<\/span> <\/span>arterijsko<\/span>g<\/span> <\/span>segmenta<\/span>.<\/span> <\/span>V<\/span>e\u0107in<\/span>a<\/span> <\/span>vaskularni<\/span>h<\/span> <\/span>hirurga<\/span> <\/span>koristi<\/span> <\/span>shunt<\/i><\/span> <\/i><\/span>ako<\/span> <\/span>se<\/span> <\/span>klemuju<\/span> <\/span>istovremeno<\/span> <\/span>dve<\/span> <\/span>supraaortalne<\/span> <\/span>grane<\/span> <\/span>i<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>pritisak<\/span> <\/span>u<\/span> <\/span>distalnom<\/span> <\/span>delu<\/span> <\/span>klemovane<\/span> <\/span>arterije<\/span> <\/span>ispod<\/span> <\/span>70<\/span> <\/span>mmHg.<\/span> <\/span>Ote\u017eavaju\u0107a <\/span>okolnost<\/span> <\/span>je<\/span> <\/span>simultan<\/span> <\/span>razvoj<\/span> <\/span>hipotenzije<\/span> <\/span>sa<\/span> <\/span>cirkulatornim<\/span> <\/span>kolapsom<\/span> <\/span>\u0161to<\/span> <\/span>smanjuje<\/span> <\/span>cerebralnu<\/span> <\/span>perfuziju.<\/span><\/p>\n

Ako<\/span> <\/span>nema<\/span> <\/span>znakova<\/span> <\/span>neurolo\u0161kog<\/span> <\/span>de<\/span>fi<\/span>cita<\/span> <\/span>lediranu<\/span> <\/span>karotidnu<\/span> <\/span>arteriju<\/span> <\/span>obavezno<\/span> <\/span>treba<\/span> <\/span>rekonstruisati.<\/span> <\/span>Kod<\/span> <\/span>uspe\u0161ne<\/span> <\/span>rekonstrukcije<\/span> <\/span>preko<\/span> <\/span>90%<\/span> <\/span>pacijenata<\/span> <\/span>prolazi<\/span> <\/span>bez<\/span> <\/span>ikakvih<\/span> <\/span>posledica.<\/span> <\/span>Ako<\/span> se <\/span>uradi<\/span> <\/span>ligatura<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> u <\/span>oko<\/span> <\/span>44%<\/span> <\/span>pacijenata<\/span> <\/span>dolazi naknadno<\/span> <\/span>do<\/span> ishemi\u010dnog cerebralnog<\/span> <\/span>insulta.<\/span> <\/span>Ako <\/span>su<\/span> <\/span>se<\/span> <\/span>razvili<\/span> <\/span>znaci<\/span> <\/span>akutnog<\/span> <\/span>neurolo\u0161kog<\/span> <\/span>de<\/span>fi<\/span>cita<\/span> <\/span>(hemiplegija,<\/span> <\/span>afazija,<\/span> <\/span>sa<\/span> <\/span>ili<\/span> <\/span>bez<\/span> <\/span>karatkotrajnih<\/span> <\/span>gubitaka<\/span> <\/span>svesti)<\/span> <\/span>tako\u0111e<\/span> <\/span>treba<\/span> <\/span>uraditi<\/span> <\/span>rekonstrukciju<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>uz<\/span> <\/span>upotrebu<\/span> <\/span>intraluminalnog<\/span> <\/span>shunt-a.<\/span> <\/span>Posle<\/span> <\/span>rekonstrukcije<\/span> <\/span>\u0107e<\/span> <\/span>u<\/span> <\/span>oko<\/span> <\/span>34%<\/span> <\/span>pacijenata<\/span> <\/span>do\u0107i<\/span> <\/span>do<\/span> <\/span>zna\u010dajnog<\/span> <\/span>neurolo\u0161kog<\/span> <\/span>pobolj\u0161anja.<\/span> <\/span>Primarna<\/span> <\/span>ligatura<\/span> <\/span>ledirane<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>indikovana<\/span> <\/span>je:<\/span> <\/span>(a)<\/span> <\/span>u<\/span> <\/span>komatoznih<\/span> <\/span>pacijenata<\/span> <\/span>sa<\/span> <\/span>distalnom<\/span> <\/span>trombozom<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije,<\/span> <\/span>(b)<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>kompjutertomografski<\/span> <\/span>mogu<\/span> <\/span>registrovati<\/span> <\/span>veliki<\/span> <\/span>areali<\/span> <\/span>ishemi\u010dnog<\/span> <\/span>infarkta<\/span> <\/span>mozga.<\/span><\/p>\n

Najbolji<\/span> <\/span>rezultati<\/span> <\/span>le\u010denja<\/span> <\/span>se<\/span> <\/span>mogu<\/span> <\/span>o\u010dekivati<\/span> <\/span>u<\/span> <\/span>pacijenata:<\/span> <\/span>(1)<\/span> <\/span>koji<\/span> <\/span>nisu<\/span> <\/span>gubili<\/span> <\/span>svest,<\/span> <\/span>\u0161to<\/span> <\/span>zna\u010di<\/span> <\/span>da<\/span> <\/span>ishemija<\/span> <\/span>nije<\/span> <\/span>zahvatila<\/span> <\/span>mo\u017edano<\/span> <\/span>stablo,<\/span> <\/span>(2)<\/span> <\/span>koji<\/span> <\/span>nemaju<\/span> <\/span>kompju-<\/span> <\/span>tertomografske<\/span> <\/span>znake<\/span> <\/span>ishemi\u010dne<\/span> <\/span>infarkcije<\/span> <\/span>mozga<\/span> <\/span>i<\/span> <\/span>(3)<\/span> <\/span>u<\/span> <\/span>kojih<\/span> <\/span>je<\/span> <\/span>rekonstrukcija<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>ura\u0111ena<\/span> <\/span>u<\/span> <\/span>okviru<\/span> <\/span>2<\/span> <\/span>do<\/span> <\/span>4<\/span> <\/span>sati.<\/span><\/p>\n

Rekonstrukcija<\/span> <\/span>ledirane<\/span> <\/span>arterije<\/span> <\/span>se<\/span> <\/span>mo\u017ee<\/span> <\/span>izvesti:<\/span><\/strong><\/p>\n

Direktna<\/b><\/span> <\/b><\/span>sutura<\/b><\/span> <\/b><\/span>bo\u010dno<\/span> <\/span>ledirane<\/span> <\/span>arterije mogu\u0107a<\/span> <\/span>je<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>o<\/span> <\/span>sekotini<\/span> <\/span>glatkih<\/span> <\/span>ivica,<\/span> <\/span>bez<\/span> <\/span>distalnih<\/span> <\/span>i<\/span> <\/span>proksimalnih<\/span> <\/span>povreda.<\/span> <\/span>Manje<\/span> <\/span>laceracije<\/span> <\/span>ili<\/span> <\/span>punktiformne<\/span> <\/span>povrede<\/span> <\/span>se<\/span> <\/span>mogu<\/span> <\/span>re\u0161iti<\/span> <\/span>bo\u010dnim<\/span> <\/span>\u0161avom.<\/span> <\/span>Primenjuje<\/span> <\/span>se<\/span> <\/span>pojedina\u010dni,<\/span> <\/span>everzioni,<\/span> <\/span>atraumatski<\/span> <\/span>\u0161av<\/span> <\/span>(Prolen)<\/span> <\/span>\u010dija<\/span> <\/span>debljina<\/span> <\/span>zavisi<\/span> <\/span>od<\/span> <\/span>promera<\/span> <\/span>arterije.<\/span><\/p>\n

Patch<\/b><\/span> <\/b><\/span>angioplastika<\/b><\/span> <\/b><\/span>se<\/span> <\/span>primenjuje<\/span> <\/span>ako<\/span> <\/span>sutura<\/span> <\/span>treba<\/span> <\/span>da<\/span> <\/span>bude<\/span> <\/span>longitudinalna<\/span> <\/span>i<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>o<\/span> <\/span>arteriji<\/span> <\/span>\u010diji<\/span> <\/span>je<\/span> <\/span>promer<\/span> <\/span>manji<\/span> <\/span>od<\/span> <\/span>8mm.<\/span> <\/span>U<\/span> <\/span>tom<\/span> <\/span>slu\u010daju<\/span> <\/span>bi<\/span> <\/span>longitudinalna<\/span> <\/span>sutura<\/span> <\/span>dovela<\/span> <\/span>do<\/span> <\/span>zna\u010dajne<\/span> <\/span>stenoze.<\/span> <\/span>Ve\u0107e <\/span>laceracije,<\/span> <\/span>pri<\/span> <\/span>kojima<\/span> <\/span>nedostaje<\/span> <\/span>deo<\/span> <\/span>zida<\/span> <\/span>arterije,<\/span> <\/span>re\u0161avaju<\/span> <\/span>se<\/span> <\/span>autovenskom<\/span> <\/span>patch<\/i><\/span> <\/i><\/span>plastikom,<\/span> <\/span>kako<\/span> <\/span>bi<\/span> <\/span>se<\/span> <\/span>izbeglo<\/span> <\/span>su\u017eenje<\/span> <\/span>arterije.<\/span> <\/span>Sintetski<\/span> <\/span>materijal<\/span> <\/span>treba<\/span> <\/span>izbegavati<\/span> <\/span>zbog<\/span> <\/span>rizika<\/span> <\/span>od<\/span> <\/span>infekcije.<\/span><\/p>\n

Direktna<\/b><\/span> <\/b><\/span>termino-terminalna<\/b><\/span> <\/b><\/span>anastomoza<\/b><\/span> <\/b><\/span>krajeva<\/span> <\/span>arterije<\/span> <\/span>\u010diji<\/span> <\/span>kontinuitet<\/span> <\/span>je<\/span> <\/span>potpuno<\/span> <\/span>prekinut<\/span> <\/span>je<\/span> <\/span>\u010desto<\/span> <\/span>mogu\u0107a<\/span> <\/span>u<\/span> <\/span>slu\u010daju<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>o<\/span> <\/span>dejstvu<\/span> <\/span>o\u0161tre<\/span> <\/span>sile.<\/span> <\/span>Ako<\/span> <\/span>postoji<\/span> <\/span>kontuzija<\/span> <\/span>okolnog<\/span> <\/span>arterijskog<\/span> <\/span>segmeta<\/span> <\/span>debridman<\/span> <\/span>arterijskih<\/span> <\/span>krajeva<\/span> <\/span>mora<\/span> <\/span>da<\/span> <\/span>bude<\/span> <\/span>opse\u017ean.<\/span> <\/span>Termino-terminalna<\/span> <\/span>anastomoza<\/span> <\/span>se<\/span> <\/span>formira<\/span> <\/span>produ\u017enim<\/span> <\/span>ili<\/span> <\/span>pojedina\u010dnim,<\/span> <\/span>evertiraju\u0107im,<\/span> <\/span>atraumatskim<\/span> <\/span>\u0161avom,<\/span> <\/span>vode\u0107i<\/span> <\/span>ra\u010duna<\/span> <\/span>da<\/span> <\/span>rekonstruisana<\/span> <\/span>arterija<\/span> <\/span>ne<\/span> <\/span>bude<\/span> <\/span>nategnuta.<\/span> <\/span>Naj\u010de\u0161\u0107a<\/span> <\/span>gre\u0161ka<\/span> <\/span>je<\/span> <\/span>\u010duvanje<\/span> <\/span>kon-<\/span> <\/span>tuzovane<\/span> <\/span>arterije.<\/span> <\/span>Posledica<\/span> <\/span>je<\/span> <\/span>tromboza.<\/span><\/p>\n

Interpozicija<\/b><\/span> <\/b><\/span>by<\/b><\/i><\/span> <\/b><\/i><\/span>pass<\/b><\/i><\/span> <\/b><\/i><\/span>grafta<\/b><\/span> <\/b><\/span>autovenskog<\/span> <\/span>(ili<\/span> <\/span>re\u0111e<\/span> <\/span>sintetskog)<\/span> <\/span>je<\/span> <\/span>neizbe\u017ena<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>kompletno<\/span> <\/span>destruiran<\/span> <\/span>du\u017ei<\/span> <\/span>segment<\/span> <\/span>arterije.<\/span> <\/span>O\u0161te\u0107eni<\/span> <\/span>delovi<\/span> <\/span>arterije<\/span> <\/span>se<\/span> <\/span>proksimalno<\/span> <\/span>i<\/span> <\/span>distalno<\/span> <\/span>moraju<\/span> <\/span>resecirati<\/span> <\/span>do<\/span> <\/span>zdravog<\/span> <\/span>segmenta.<\/span> <\/span>Pre<\/span> <\/span>formiranja<\/span> <\/span>anastomoza<\/span> <\/span>proksimalni<\/span> i <\/span>distalni<\/span> <\/span>arterijski<\/span> <\/span>segment<\/span> <\/span>provere<\/span> se<\/span> <\/span>balon<\/span> <\/span>kateterom<\/span> <\/span>(Fogarty)<\/span> <\/span>da<\/span> <\/span>bi<\/span> <\/span>smo<\/span> <\/span>odstranili<\/span> <\/span>prizidne<\/span> <\/span>trombe<\/span> <\/span>i<\/span> <\/span>uverili<\/span> <\/span>se<\/span> <\/span>da<\/span> <\/span>nema<\/span> <\/span>udaljenih<\/span> <\/span>intimalnih<\/span> <\/span>lezija.<\/span> <\/span>U<\/span> <\/span>tom<\/span> <\/span>slu\u010daju<\/span> <\/span>du\u017eina<\/span> <\/span>implantiranog<\/span> <\/span>by<\/i><\/span> <\/i><\/span>pass<\/i><\/span>-a<\/span> <\/span>mora<\/span> <\/span>biti<\/span> <\/span>ve\u0107a.<\/span><\/p>\n

Autovenski graft (vena<\/i> <\/i>saphena<\/i> <\/i>magna<\/i> <\/i>sa iste noge) se preferira u odnosu na sintetske graftove zbog ve\u0107e otpornosti na infekciju. Autovenski graft je suvi\u0161e malog kalibra da bi se mogao primenjivati za rekonstrukciju arterija u grudnom ko\u0161u. U tom slu\u010daju se mora primeniti sintetski graft. Arterija i graft moraju biti prese\u010dani koso na krajevima, da bi se izbegla stenoza termino-terminalne anastomoze.<\/p>\n<\/div>\n

\"\"<\/p>\n

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Traumatska lezija po\u010detnog (intratorakalnog) dela leve subklavijalne arterije zahteva levu torakotomiju i rekonstrukciju aorto-subklavijalnim bypass-om (obi\u010dno graft od sintetskog materijala, impregnirani Dacron).<\/em><\/p>\n<\/div>\n

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Ubodne i prostrelne povrede aortnog luka i njegovih grana su opasnije nego sli\u010dne povrede srca (aortni zid je tanji od sr\u010danog, dijastolni pritisak je ve\u0107i, medijastinalni, odnosno retroperitonealni tkivni otpor krvarenju je manji).<\/p>\n

Lezije aortnog luka i po\u010detnog dela njegovih grana (truncu<\/i>s<\/i>brachiocephalicu<\/i>s<\/i> <\/i>i aa.<\/i> carotis <\/i>communis<\/i>) zahtevaju hitno otvaranje toraksa medijalnom<\/b> <\/b>sternoto<\/b>mijom<\/b><\/span>.<\/span> <\/span>Ovo<\/span> <\/span>je<\/span> <\/span>pristup<\/span> <\/span>koji<\/span> <\/span>se<\/span> <\/span>lako<\/span> <\/span>izvodi,<\/span> <\/span>doro<\/span> <\/span>toleri\u0161e<\/span> <\/span>i<\/span> <\/span>sigurno<\/span> <\/span>zatvara.<\/span> <\/span>Me<\/span>dijalna<\/span> <\/span>sternotomija<\/span> <\/span>eksponira<\/span> <\/span>srce,<\/span> <\/span>velike<\/span> <\/span>vene<\/span> <\/span>i<\/span> <\/span>velike<\/span> <\/span>arterije<\/span> <\/span>medijastinuma.<\/span> <\/span>Jedino<\/span> <\/span>ostaje<\/span> <\/span>te\u0161ko<\/span> <\/span>pristupa\u010dan<\/span> <\/span>po\u010detni<\/span> <\/span>deo<\/span> <\/span>leve<\/span> <\/span>subklavijalne<\/span> <\/span>arterije.<\/span><\/p>\n

Lezije<\/span> <\/span>leve<\/span> <\/span>subklavijalne<\/span> <\/span>arterije<\/span> <\/span>i<\/span> <\/span>descendentne<\/span> <\/span>aorte<\/span> <\/span>zahtevaju<\/span> <\/span>urgentnu<\/span> <\/span>levu<\/b><\/span> <\/b><\/span>torakotomiju<\/b><\/span> <\/b><\/span>(III-VI<\/span> <\/span>interkostalni<\/span> <\/span>prostor).<\/span> <\/span>Prvi<\/span> <\/span>cilj<\/span> <\/span>operacije<\/span> <\/span>je<\/span> <\/span>uspostavljanje<\/span> <\/span>proksimalne<\/span> <\/span>i<\/span> <\/span>distalne<\/span> <\/span>kontrole krvarenja<\/b><\/span> <\/b><\/span>(prvo<\/span> <\/span>digitalnim<\/span> <\/span>pritiskom,<\/span> <\/span>a<\/span> <\/span>potom:<\/span> <\/span>popre\u010dno<\/span> <\/span>klemovanje,<\/span> <\/span>tangencijalno<\/span> <\/span>klemovanje<\/span> <\/span>–<\/span> <\/span>Satinsky,<\/span> <\/span>ili<\/span> <\/span>postavljanje<\/span> <\/span>balon<\/span> <\/span>katetera<\/span> <\/span>–<\/span> <\/span>Fogarty).<\/span><\/p>\n

Bolesnik<\/span> sa <\/span>inkompletnom<\/span> <\/span>rupturom<\/span> <\/span>supraaortalnih<\/span> <\/span>grana<\/span> <\/span>ili<\/span> <\/span>aorte<\/span> je u <\/span>stanju<\/span> <\/span>te\u0161kog<\/span> <\/span>\u0161oka.<\/span> <\/span>Postoje<\/span> <\/span>znaci<\/span> <\/span>kompresije<\/span> <\/span>medijastinuma<\/span> <\/span>(dispneja,<\/span> <\/span>staza<\/span> <\/span>u<\/span> <\/span>slivu<\/span> <\/span>gornje<\/span> <\/span>\u0161uplje<\/span> <\/span>vene,<\/span> <\/span>jak<\/span> <\/span>bol<\/span> u <\/span>grudnom<\/span> <\/span>ko\u0161u<\/span> sa <\/span>zra\u010denjem<\/span> u <\/span>levo,<\/span> <\/span>odsustvo<\/span> <\/span>pulsa<\/span> <\/span>na<\/span> <\/span>karotidnoj<\/span> <\/span>arteriji<\/span> <\/span>i<\/span> <\/span>razli\u010diti<\/span> <\/span>arterijski<\/span> <\/span>pritisci<\/span> <\/span>na<\/span> <\/span>ekstremitetima).<\/span> <\/span>Pogor\u0161anje<\/span> <\/span>op\u0161teg<\/span> <\/span>stanja,<\/span> <\/span>poja\u010danje<\/span> <\/span>intratorakalnog<\/span> <\/span>bola<\/span> i <\/span>pojava<\/span> <\/span>hematotoraksa<\/span> <\/span>ukazuju<\/span> na<\/span> <\/span>rupturu<\/span> <\/span>u<\/span> <\/span>razvoju.<\/span> <\/span>Urgentna<\/span> <\/span>aortogra<\/span>fi<\/span>ja<\/span> <\/span>prikaza\u0107e<\/span> <\/span>mesto<\/span> <\/span>inkompletne<\/span> <\/span>rupture<\/span> <\/span>i<\/span> <\/span>pulsiraju\u0107i<\/span> <\/span>hematom.<\/span><\/p>\n

Odmah<\/span> <\/span>treba<\/span> <\/span>obezbediti<\/span> <\/span>nekoliko<\/span> <\/span>venskih<\/span> <\/span>pristupa<\/span> <\/span>(za<\/span> <\/span>merenje<\/span> <\/span>centralnog<\/span> <\/span>vensko<\/span>g <\/span>pritisk<\/span>ai <\/span>z<\/span>a<\/span> <\/span>supstitucij<\/span>u <\/span>derivat<\/span>a<\/span>krvi<\/span>,<\/span> <\/span>plazm<\/span>a <\/span>ekspander<\/span>ai <\/span>auto transfuziju<\/span>)<\/span> <\/span>i<\/span> <\/span>arterijsku<\/span> <\/span>liniju<\/span> <\/span>za<\/span> <\/span>monitoring.<\/span><\/span><\/p>\n<\/div>\n

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Grudni<\/span> <\/span>ko\u0161<\/span> <\/span>se<\/span> <\/span>otvara<\/span> <\/span>levom<\/b><\/span> <\/b><\/span>torakotomijom<\/b><\/span> <\/b><\/span>kroz<\/span> <\/span>peti<\/span> <\/span>me\u0111urebarni<\/span> <\/span>prostor.<\/span> <\/span>Obi\u010dno<\/span> <\/span>se<\/span> <\/span>primenjuje<\/span> <\/span>protektivni<\/b><\/span> <\/b><\/span>temporerni<\/b><\/span> <\/b><\/span>shunt<\/b><\/i><\/span> <\/b><\/i><\/span>od<\/b><\/span> <\/b><\/span>leve<\/b><\/span> <\/b><\/span>pretkomore<\/b><\/span> <\/b><\/span>(aurikula)<\/b><\/span> <\/b><\/span>na<\/b><\/span> <\/b><\/span>levu<\/b><\/span> <\/b><\/span>ilija\u010dnu<\/b><\/span> <\/b><\/span>arteriju<\/b><\/span>.<\/span> <\/span>Ovim<\/span> <\/span>sistemom<\/span> <\/span>cevi<\/span> <\/span>se<\/span> <\/span>preko<\/span> <\/span>roler-pumpe<\/span> <\/span>prebacuje<\/span> <\/span>u<\/span> <\/span>distalne<\/span> <\/span>delove<\/span> <\/span>torakoabdominalne<\/span> <\/span>aorte<\/span> <\/span>oko<\/span> <\/span>30-40%<\/span> <\/span>volumena.<\/span> <\/span>Na <\/span>taj<\/span> <\/span>na\u010din<\/span> <\/span>spre\u010davamo<\/span> <\/span>akutnu<\/span> <\/span>insu<\/span>fi<\/span>cijenciju<\/span> <\/span>leve<\/span> <\/span>komore.<\/span> <\/span>Osim<\/span> <\/span>toga,<\/span> <\/span>prevenira<\/span> <\/span>se<\/span> <\/span>ekscesivan<\/span> <\/span>skok<\/span> <\/span>tenzije<\/span> u <\/span>cerebralnoj<\/span> <\/span>cirkulaciji<\/span> <\/span>posle<\/span> <\/span>klemovanja<\/span> <\/span>aortnog<\/span> <\/span>luka.<\/span> <\/span>Na<\/span> <\/span>drugoj<\/span> <\/span>strani,<\/span> <\/span>popravlja<\/span> <\/span>se<\/span> <\/span>arterijska<\/span> <\/span>irigacija<\/span> <\/span>i<\/span> <\/span>oksigenacija<\/span> <\/span>bubrega<\/span> <\/span>i<\/span> <\/span>ki\u010dmene<\/span> <\/span>mo\u017edine,<\/span> <\/span>preveniraju\u0107i<\/span> <\/span>njihovu<\/span> <\/span>ishemiju.<\/span> <\/span>Rekonstrukcija<\/span> <\/span>rupturirane<\/span> <\/span>arterije<\/span> <\/span>i\/ili<\/span> <\/span>aorte<\/span> <\/span>se<\/span> <\/span>zavr\u0161ava<\/span> <\/span>interponiranjem<\/span> <\/span>sintetskog<\/span> <\/span>grafta.<\/span><\/p>\n

Na<\/span><\/span>taj<\/span> <\/span>na\u010din<\/span> <\/span>spre\u010davamo<\/span> <\/span>akutnu<\/span> <\/span>insu<\/span>fi<\/span>cijenciju<\/span> <\/span>leve<\/span> <\/span>komore.<\/span> <\/span>Osim<\/span> <\/span>toga,<\/span> <\/span>prevenira<\/span> <\/span>se<\/span> <\/span>ekscesivan<\/span> <\/span>skok<\/span> <\/span>tenzije<\/span> u <\/span>cerebralnoj<\/span> <\/span>cirkulaciji<\/span> <\/span>posle<\/span> <\/span>klemovanja<\/span> <\/span>aortnog<\/span> <\/span>luka.<\/span> <\/span>Na<\/span> <\/span>drugoj<\/span> <\/span>strani,<\/span> <\/span>popravlja<\/span> <\/span>se<\/span> <\/span>arterijska<\/span> <\/span>irigacija<\/span> <\/span>i<\/span> <\/span>oksigenacija<\/span> <\/span>bubrega<\/span> <\/span>i<\/span> <\/span>ki\u010dmene<\/span> <\/span>mo\u017edine,<\/span> <\/span>preveniraju\u0107i<\/span> <\/span>njihovu<\/span> <\/span>ishemiju.<\/span> <\/span>Rekonstrukcija<\/span> <\/span>rupturirane<\/span> <\/span>arterije<\/span> <\/span>i\/ili<\/span> <\/span>aorte<\/span> <\/span>se<\/span> <\/span>zavr\u0161ava<\/span> <\/span>interponiranjem<\/span> <\/span>sintetskog<\/span> <\/span>grafta.<\/span><\/p>\n

Kod<\/span> <\/span>povreda<\/span> <\/span>distalnog<\/span> <\/span>dela<\/span> <\/span>aortnog<\/span> <\/span>luka<\/span> <\/span>i<\/span> <\/span>njegovih<\/span> <\/span>grana<\/span> <\/span>koje<\/span> <\/span>se<\/span> <\/span>mogu<\/span> <\/span>rekon-<\/span> <\/span>struisati<\/span> u<\/span> <\/span>periogu<\/span> <\/span>kra\u0107em<\/span> <\/span>od 40<\/span> <\/span>minuta<\/span> <\/span>nije<\/span> <\/span>neophodna<\/span> <\/span>ekstrakorporalna<\/span> <\/span>cirku-<\/span> <\/span>lacija.<\/span> <\/span>Ali<\/span> <\/span>se<\/span> <\/span>te\u0161ko<\/span> <\/span>mo\u017eemo<\/span> <\/span>odre\u0107i<\/span> <\/span>protektivnog<\/span> <\/span>atrio-femoralnog<\/span> <\/span>ili<\/span> <\/span>subklavio-<\/span> <\/span>femoralnog<\/span> <\/span>shunt<\/i><\/span>-a.<\/span> <\/span>Procenat<\/span> <\/span>ishemi\u010dkih<\/span> <\/span>o\u0161te\u0107enja<\/span> <\/span>ki\u010dmene<\/span> <\/span>mo\u017edine<\/span> <\/span>i<\/span> <\/span>bubrega<\/span> <\/span>je<\/span> <\/span>manji<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>koristi<\/span> <\/span>protektivni<\/span> <\/span>shunt<\/i><\/span>.<\/span> <\/span>Bitno<\/span> <\/span>je<\/span> <\/span>da<\/span> <\/span>klemovani<\/span> <\/span>segment<\/span> <\/span>bude<\/span> <\/span>\u0161to<\/span> <\/span>kra\u0107i<\/span> <\/span>i<\/span> <\/span>da<\/span> <\/span>rekonstrukcija<\/span> <\/span>bude<\/span> <\/span>ure\u0111ena<\/span> <\/span>\u0161to<\/span> <\/span>br\u017ee.<\/span> <\/span>Bez<\/span> <\/span>naknadnog<\/span> <\/span>krvarenja.<\/span><\/p>\n

Ekstra-anatomski<\/b><\/span> <\/b><\/span>by<\/b><\/span> <\/b><\/span>pass<\/b><\/span> <\/b><\/span>se<\/span> <\/span>mo\u017ee<\/span> <\/span>primeniti<\/span> <\/span>kod<\/span> <\/span>lezija<\/span> <\/span>supraaortalnih<\/span> <\/span>grana<\/span> <\/span>kad<\/span> <\/span>\u017eelimo<\/span> <\/span>da<\/span> <\/span>izbegnemo<\/span> <\/span>region<\/span> <\/span>koji<\/span> <\/span>je<\/span> <\/span>kod<\/span> <\/span>otvorene<\/span> <\/span>povrede<\/span> <\/span>kontaminiran<\/span> <\/span>bakterijama.<\/span> <\/span>Dolazi<\/span> <\/span>u<\/span> <\/span>obzir<\/span> <\/span>karotiko-subklavijalni,<\/span> <\/span>aksilo-aksilarni,<\/span> <\/span>karotiko-<\/span> <\/span>karotidni<\/span> <\/span>by<\/i><\/span> <\/i><\/span>pass<\/i><\/span>.<\/span><\/p>\n

Transpozicija<\/span> <\/span>supraaortalnih<\/span> <\/span>grana<\/span> <\/span>je<\/span> <\/span>najelegantnije<\/span> <\/span>re\u0161enje<\/span> <\/span>koje<\/span> <\/span>mo\u017ee<\/span> <\/span>da<\/span> <\/span>zameni<\/span> <\/span>ekstra-anatomski<\/span> <\/span>by<\/span> <\/span>pass<\/span> <\/span>ako<\/span> <\/span>\u017eelimo<\/span> <\/span>da<\/span> <\/span>izbegnemo<\/span> <\/span>implantaciju<\/span> <\/span>sintetskog<\/span> <\/span>materijala<\/span> <\/span>u<\/span> <\/span>kontaminiranu<\/span> <\/span>sredinu.<\/span> <\/span>Transpoziciju<\/span> <\/span>mo\u017eemo<\/span> <\/span>da<\/span> <\/span>primenimo<\/span> <\/span>pod<\/span> <\/span>uslovom<\/span> <\/span>da<\/span> <\/span>nije<\/span> <\/span>lediran<\/span> <\/span>suvi\u0161e<\/span> <\/span>dug<\/span> <\/span>arterijski<\/span> <\/span>segment<\/span> <\/span>i<\/span> <\/span>da<\/span> <\/span>je<\/span> <\/span>o\u010duvana<\/span> <\/span>susedna<\/span> <\/span>prolazna<\/span> <\/span>arterija.<\/span><\/p>\n

Nakon<\/b><\/span> <\/b><\/span>zavr\u0161etka<\/b><\/span> <\/b><\/span>arterijske<\/b><\/span> <\/b><\/span>rekonstrukcije<\/b><\/span> <\/b><\/span>po\u017eeljno<\/span> <\/span>je<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>uradi<\/span> <\/span>kontrolna<\/span> <\/span>intraoperativna<\/span> <\/span>arteriogra<\/span>fi<\/span>ja.<\/span> <\/span>Treba<\/span> <\/span>uraditi<\/span> <\/span>opse\u017ean<\/span> <\/span>debridman<\/span> <\/span>rane<\/span> <\/span>i<\/span> <\/span>ukloniti<\/span> <\/span>svo<\/span> <\/span>nekroti\u010dno<\/span> <\/span>i<\/span> <\/span>eventualno<\/span> <\/span>kontaminirano<\/span> <\/span>tkivo.<\/span> <\/span>Ranu<\/span> <\/span>treba<\/span> <\/span>obilno<\/span> <\/span>isprati<\/span> <\/span>rastvorima<\/span> <\/span>antiseptika<\/span> <\/span>i<\/span> <\/span>antibiotika.<\/span> <\/span>Na<\/span> <\/span>kraju<\/span> <\/span>se<\/span> <\/span>postavlja<\/span> <\/span>aspiraciona<\/span> <\/span>drena\u017ea<\/span> <\/span>(24-48h).<\/span> <\/span>Rana<\/span> <\/span>se<\/span> <\/span>zatvara<\/span> <\/span>dobro<\/span> <\/span>razmakutim<\/span> <\/span>pojedina\u010dnim<\/span> <\/span>\u0161avovima,<\/span> <\/span>bez<\/span> <\/span>tenzije,<\/span> <\/span>\u010desto<\/span> <\/span>i<\/span> <\/span>bez<\/span> <\/span>zatvaranja<\/span> <\/span>fascije<\/span> <\/span>(na<\/span> <\/span>ekstremitetima).<\/span><\/p>\n

Neposredno<\/b><\/span> <\/b><\/span>postoperativno<\/b><\/span> <\/b><\/span>le\u010denje<\/b><\/span> <\/b><\/span>podrazumeva:<\/span> <\/span>intenzivan<\/span> <\/span>neurolo\u0161ki<\/span> <\/span>monitoring,<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>potrebno<\/span> <\/span>dopunsku<\/span> <\/span>dijagnostiku<\/span> <\/span>(CT<\/span> <\/span>i<\/span> <\/span>MRI<\/span> <\/span>mozga),<\/span> <\/span>monitoring<\/span> <\/span>vitalnih<\/span> <\/span>funkcija<\/span> <\/span>(naro\u010dito<\/span> <\/span>kardiorespiratornih)<\/span> <\/span>regulisanje<\/span> <\/span>hidroelektrolitnog<\/span> <\/span>statusa,<\/span> <\/span>korigovanje<\/span> <\/span>anemije,<\/span> <\/span>pra\u0107enje<\/span> <\/span>diureze<\/span> <\/span>i<\/span> <\/span>urinarne<\/span> <\/span>acidoze<\/span> <\/span>itd.<\/span> <\/span>Postoperativno<\/span> <\/span>treba<\/span> <\/span>nastaviti<\/span> <\/span>sa<\/span> <\/span>antibioticima<\/span> <\/span>u<\/span> <\/span>visokim<\/span> <\/span>dozama,<\/span> <\/span>koji<\/span> <\/span>su<\/span> <\/span>zapo\u010deti<\/span> <\/span>pre<\/span> <\/span>i<\/span> <\/span>intraoperativno,<\/span> <\/span>uz<\/span> <\/span>antibiogram.<\/span><\/p>\n

Ukoliko<\/span> <\/span>je<\/span> <\/span>du\u017eina<\/span> <\/span>trajanja<\/span> <\/span>ishemije<\/span> <\/span>ve\u0107a<\/span> <\/span>utoliko<\/span> <\/span>je<\/span> <\/span>postrevaskularizacioni<\/span> <\/span>sindrom<\/span> <\/span>te\u017ei.<\/span> <\/span>Mozak<\/span> <\/span>i<\/span> <\/span>mi\u0161i\u0107i<\/span> <\/span>su<\/span> <\/span>posebno<\/span> <\/span>skloni<\/span> <\/span>postreperfuzionom<\/span> <\/span>otoku.<\/span> <\/span>Obzirom<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>nalaze<\/span> <\/span>u<\/span> <\/span>neelasti\u010dnim<\/span> <\/span>pregradama<\/span> <\/span>mo\u017ee<\/span> <\/span>se<\/span> <\/span>razviti<\/span> <\/span>\u2018kompartment<\/span> <\/span>sindrom\u201d.<\/span> <\/span>U<\/span> <\/span>tom<\/span> <\/span>slu\u010daju<\/span> <\/span>dolazi<\/span> <\/span>do<\/span> <\/span>kompresivne<\/span> <\/span>ireverzibilne<\/span> <\/span>destrukcije<\/span> <\/span>plemenitog<\/span> <\/span>tkiva.<\/span><\/p>\n

Tako<\/span> se<\/span> <\/span>uspe\u0161na<\/span> <\/span>revaskularizacija<\/span> <\/span>mo\u017ee<\/span> <\/span>zavr\u0161iti<\/span> <\/span>hemorag\u010dnim<\/span> <\/span>infarktom<\/span> <\/span>mozga<\/span> <\/span>zbog<\/span> <\/span>postrevaskularizacionog<\/span> <\/span>edema<\/span> <\/span>ishemi\u010dnog<\/span> <\/span>tkiva.<\/span> <\/span>Diuretska<\/span> <\/span>terapija<\/span> <\/span>je<\/span> <\/span>obavezna<\/span> <\/span>i<\/span> <\/span>mora<\/span> <\/span>biti<\/span> <\/span>dozirana<\/span> <\/span>shodno<\/span> <\/span>neurolo\u0161kom<\/span> <\/span>i<\/span> <\/span>CT<\/span> <\/span>nalazu.<\/span> <\/span><\/p>\n

Kraniotomija<\/span><\/strong> <\/span>je<\/span> <\/span>ponekad<\/span> <\/span>neizbe\u017ena<\/span> <\/span>da<\/span> <\/span>bi<\/span> <\/span>se<\/span> <\/span>prevenirala<\/span> <\/span>hernijacija<\/span> <\/span>mozga<\/span> <\/span>sa<\/span> <\/span>letalnim<\/span> <\/span>ishodom.<\/span> <\/span>Fasciotomija revaskularizovanog gornjeg ekstremiteta je retko neophodna.<\/p>\n

Postoperativna antikoagulaciona terapija daje se samo:
(a) ako postoji simultana venska staza zbog ligature susedne vene ili
(b) ako se radi o starijim pacijentima sa kardiolo\u0161kim razlozima za antikoagulantnu terapiju. Antitrombocitna terapija se podrazumeva.<\/p>\n<\/div>\n


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

POVREDE ARTERIJA KOJE ISHRANJUJU MOZAK 17.2. LE\u010cENJE ARTERIJSKIH POVREDA LE\u010cENJE ARTERIJSKIH POVREDA Neposredni cilj je zaustavljanje krvarenja, nadoknada volumena, prevencija \u0161oka i spa\u0161avanje \u017eivota, a potom rekonstrukcija povre\u0111ene arterije uz o\u010duvanje funkcije mozga i\/ili gornjeg ekstremiteta. Zustavljanje krvarenja je urgentna mera. Mo\u017ee biti: (a) privremeno ili (b) definitivno. Privremeno zaustavljanje krvarenja je mogu\u0107e ako se […]<\/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-4253","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n17.2. 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