{"id":4589,"date":"2023-02-17T09:17:21","date_gmt":"2023-02-17T09:17:21","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=4589"},"modified":"2023-02-24T10:16:24","modified_gmt":"2023-02-24T10:16:24","slug":"21-endovaskularna-hirurgija","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=4589","title":{"rendered":"21. ENDOVASKULARNA HIRURGIJA"},"content":{"rendered":"

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

<\/p>\n

ENDOVASKULARNA HIRURGIJA<\/h1>\n

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

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A few bad reasons for doing something neutralise all the good reasons for doing it.
<\/i>Bertrand<\/i> <\/i>Russel<\/i><\/p>\n<\/div>\n

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Perkutane<\/span> <\/span>endovaskularne<\/span> <\/span>tehnike<\/span><\/strong> <\/span>su<\/span> <\/span>manje<\/span> <\/span>traumati\u010dne<\/span> <\/span>za<\/span> <\/span>pacijenta<\/span> <\/span>i<\/span> <\/span>primenjivije<\/span> <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>sa<\/span> <\/span>visokim<\/span> <\/span>rizikom.<\/span> <\/span>Endovaskularna<\/span> <\/span>hirurgija<\/span> <\/span>nije<\/span> <\/span>limitirana<\/span> <\/span>samo<\/span> <\/span>na<\/span> <\/span>karotidne<\/span> <\/span>arterije,<\/span> <\/span>ve\u0107<\/span> <\/span>omogu\u0107ava<\/span> <\/span>revaskularizaciju<\/span> <\/span>supraaortalnih<\/span> <\/span>grana.<\/span> <\/span><\/p>\n

Me\u0111utim,<\/span> <\/span>perkutana<\/span> <\/span>transluminalna<\/span> <\/span>balon<\/span> <\/span>angioplastika<\/span> <\/span>(<\/span>Percutaneous<\/span> <\/span>Transluminal<\/span> <\/span>Angioplasty<\/span> <\/span>PTA)<\/span> <\/span><\/strong><\/em>ima<\/span> <\/span>limitiraju\u0107e<\/span> <\/span>faktore<\/span> <\/span>zavisno<\/span> <\/span>od<\/span> <\/span>morfologije<\/span> <\/span>lezije<\/span> <\/span>i<\/span> <\/span>starosti<\/span> <\/span>pacijenta<\/span><\/p>\n

Tehnika<\/b><\/span> <\/b><\/span>izvo\u0111enja<\/b><\/span> <\/b><\/span>perkutane<\/b><\/span> <\/b><\/span>transluminalne<\/b><\/span> <\/b><\/span>dilatacije<\/b><\/span> <\/b><\/span>(PTA)<\/b><\/span><\/p>\n

Najbolje<\/span> <\/span>mesto<\/span> <\/span>za<\/span> <\/span>arterijsku<\/span> <\/span>punkciju<\/span> <\/span>kod<\/span> <\/span>PTA<\/span> <\/span>je<\/span> <\/span>a.femoralis<\/i><\/span> <\/i><\/span>comunis,<\/i><\/span> <\/i><\/span>zbog<\/span> <\/span>malog<\/span> <\/span>broja<\/span> <\/span>lokalnih<\/span> <\/span>komplikacija<\/span> <\/span>i<\/span> <\/span>mogu\u0107nosti<\/span> <\/span>intervencije<\/span> <\/span>na<\/span> <\/span>svim<\/span> <\/span>supraaortalnim<\/span> <\/span>granama.<\/span> <\/span>Ako<\/span> <\/span>postoji<\/span> <\/span>okluzivna<\/span> <\/span>ili<\/span> <\/span>aneurizmatska<\/span> <\/span>bolest<\/span> <\/span>aorto-<\/span> <\/span>femoralnog<\/span> <\/span>segmenta<\/span> <\/span>mora<\/span> <\/span>se<\/span> <\/span>tra\u017eiti<\/span> <\/span>druga<\/span> <\/span>alternativa<\/span> <\/span>(a.axillaries<\/i><\/span> <\/i><\/span>ili<\/i><\/span> <\/i><\/span>a.<\/i><\/span> <\/i><\/span>brachalis)<\/i><\/span>.<\/span><\/p>\n

Kad<\/span> <\/span>se<\/span> <\/span>kateterom<\/span> <\/span>do<\/span> <\/span>supraaortalnih<\/span> <\/span>grana<\/span> <\/span>prilazi<\/span> <\/span>iz<\/span> <\/span>arterija<\/span> <\/span>gornjih<\/span> <\/span>ekstremiteta<\/span> <\/span>mogu\u0107nosti<\/span> <\/span>za<\/span> <\/span>njegovu<\/span> <\/span>manipulaciju<\/span> <\/span>su<\/span> <\/span>ograni\u010dene.<\/span> <\/span><\/p>\n

Kod<\/span> <\/span>plasiranja<\/span> <\/span>stenta<\/span> <\/span>(promer<\/span> <\/span>7F<\/span> <\/span>ili<\/span> <\/span>8F)<\/span> <\/span>nekad<\/span> <\/span>je<\/span> <\/span>bolje<\/span> <\/span>hirur\u0161ki<\/span> <\/span>ispreparisati<\/span> <\/span>brahijalnu<\/span> <\/span>arteriju,<\/span> <\/span>po\u0161to<\/span> <\/span>je<\/span> <\/span>verovatno\u0107a<\/span> <\/span>lokalnih<\/span> <\/span>arterijskih<\/span> <\/span>komplikacija<\/span> <\/span>velika.<\/span> <\/span>Lokalne<\/span> <\/span>komplikacije<\/span> <\/span>na<\/span> <\/span>mestu<\/span> <\/span>punkcije<\/span> <\/span>su<\/span> <\/span>disekcija,<\/span> <\/span>okluzija,<\/span> <\/span>pseudoaneurizma,<\/span> <\/span>retroperitonealni<\/span> <\/span>hematom<\/span> <\/span>(1-3%).<\/span> <\/span>Ako<\/span> <\/span>se<\/span> <\/span>punktira<\/span> <\/span>aksilarna<\/span> <\/span>ili<\/span> <\/span>brahijalna<\/span> <\/span>arterija<\/span> <\/span>komplikacije<\/span> <\/span>su<\/span> <\/span>\u010de\u0161\u0107e<\/span> <\/span>(3-18%).<\/span> <\/span>Postoji<\/span> <\/span>mogu\u0107nost<\/span> <\/span>pristupa<\/span> <\/span>za<\/span> <\/span>PTA<\/span> <\/span>direktnom<\/span> <\/span>punkcijom<\/span> <\/span>a.carotis<\/b><\/i><\/span> <\/b><\/i><\/span>communis.<\/b><\/i><\/span><\/p>\n

Kateterizacija<\/b><\/span> <\/b><\/span>po<\/b><\/span> <\/b><\/span>Seldinger<\/b><\/i><\/span>-u:<\/b><\/span> <\/b><\/span>Nakon<\/span> <\/span>punkcije<\/span> <\/span>kroz<\/span> <\/span>iglu,<\/span> <\/span>ubodenu<\/span> <\/span>u<\/span> <\/span>arteriju,<\/span> <\/span>uvodi<\/span> <\/span>se<\/span> <\/span>\u017eica<\/span> <\/span>vodilja<\/span> <\/span>(<\/span>Guide<\/i><\/span> <\/i><\/span>wire<\/i><\/span>). <\/span>Ona<\/span> <\/span>je<\/span> <\/span>tanja<\/span> <\/span>od<\/span> <\/span>1<\/span> <\/span>mm,<\/span> <\/span>presvu\u010dena<\/span> <\/span>je<\/span> <\/span>mate-<\/span> <\/span>rijalo<\/span>m<\/span> <\/span>koj<\/span>i<\/span> <\/span>j<\/span>e<\/span> <\/span>\u010din<\/span>i<\/span> <\/span>glatkom<\/span>.<\/span> <\/span>V<\/span>odi<\/span>\u010d<\/span> <\/span>ostaj<\/span>e<\/span> <\/span>u<\/span> <\/span>arteriji<\/span>,<\/span> <\/span>do<\/span>k<\/span> <\/span>s<\/span>e<\/span> <\/span>igl<\/span>a<\/span> <\/span>izvadi<\/span>.<\/span> <\/span>V<\/span>odi<\/span>\u010d<\/span> <\/span>j<\/span>e<\/span> <\/span>duga\u010dak,<\/span> <\/span>ve\u0107i<\/span> <\/span>deo<\/span> <\/span>je<\/span> <\/span>van<\/span> <\/span>arterije,<\/span> <\/span>i<\/span> <\/span>slu\u017ei<\/span> <\/span>za<\/span> <\/span>manipulaciju.<\/span> <\/span>Da<\/span> <\/span>bi<\/span> <\/span>se<\/span> <\/span>preko<\/span> <\/span>vodi\u010da,<\/span> <\/span>jedan<\/span> <\/span>kateter<\/span> <\/span>mogao<\/span> <\/span>uklanjali<\/span> <\/span>a<\/span> <\/span>drugi<\/span> <\/span>uvoditi.<\/span> <\/span>Na<\/span> <\/span>vodi\u010d<\/span> <\/span>se<\/span> <\/span>navu\u010de<\/span> <\/span>dilatator,<\/span> <\/span>samo<\/span> <\/span>da<\/span> <\/span>bi<\/span> <\/span>se<\/span> <\/span>pro\u0161irio<\/span> <\/span>kanal<\/span> <\/span>i<\/span> <\/span>olak\u0161alo<\/span> <\/span>dalje<\/span> <\/span>manipulisanje.<\/span> <\/span>Dilatator<\/span> <\/span>se<\/span> <\/span>ukloni,<\/span> <\/span>a<\/span> <\/span>na<\/span> <\/span>vodi\u010d<\/span> <\/span>se<\/span> <\/span>navla\u010di<\/span> <\/span>\u0161ira<\/span> <\/span>cev\u010dica<\/span> <\/span>(<\/span>sheath<\/i><\/span>,<\/span> <\/span>ko\u0161uljica).<\/span> <\/span>Na<\/span> <\/span>svom<\/span> <\/span>spolja\u0161njem<\/span> <\/span>kraju<\/span> <\/span>\u201e<\/span>sheath<\/i><\/span>\u201d<\/span> <\/span>ima<\/span> <\/span>valvulu-ventil,<\/span> <\/span>koja<\/span> <\/span>spre\u010dava<\/span> <\/span>da<\/span> <\/span>krv<\/span> <\/span>pored<\/span> <\/span>\u017eice<\/span> <\/span>isti\u010de,<\/span> <\/span>dok<\/span> <\/span>istovremeno<\/span> <\/span>ne<\/span> <\/span>predstavlja<\/span> <\/span>prepreku<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>uvla\u010de<\/span> <\/span>kateteri<\/span> <\/span>razli\u010ditih<\/span> <\/span>namena.<\/span> <\/span>Naime,<\/span> <\/span>da<\/span> <\/span>bi<\/span> <\/span>se<\/span> <\/span>u\u0161lo<\/span> <\/span>u<\/span> <\/span>te\u0161ko<\/span> <\/span>pristupa\u010dne<\/span> <\/span>arterije<\/span> <\/span>potrebni<\/span> <\/span>su<\/span> <\/span>kateteri<\/span> <\/span>\u010diji<\/span> <\/span>su<\/span> <\/span>vrhovi<\/span> <\/span>specijalno<\/span> <\/span>oblikovani<\/span> <\/span>(selektivna<\/span> <\/span>i<\/span> <\/span>supraselektivna<\/span> <\/span>kateterizacija).<\/span><\/p>\n<\/div>\n

\"\"<\/p>\n

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Punkcija femoralne arterije i perkutano uvo\u0111enje katetera u arterijski sistem po Seldinger-u.<\/em><\/p>\n<\/div>\n

\"\"<\/p>\n

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Nakon uvo\u0111enja ko\u0161uljice (sheath), preko vodi\u010da, mo\u017eemo u arteriju uvoditi katetere razli\u010ditih promera i namena.<\/em><\/p>\n<\/div>\n

\"\"<\/p>\n

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Preko specijalnog nastavka mo\u017ee se povremeno inicirati kontrast za proveru polo\u017eaja katetera.<\/em><\/p>\n

\n<\/div>\n

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Transluminalna<\/b> <\/b>dilatacija<\/b> <\/b>arterije<\/b> <\/b>balonom:<\/b> <\/b>Seldinger<\/i>-ovom tehnikom u arteriju se uvodi kateter, na \u010dijem vrhu je balon za dilataciju. Vodi\u010dem se pro\u0111e su\u017eeno mesto. Potom se na \u017eicu navu\u010de kateter sa balonom. Naduvavanje balona je automatizovano sa zadatim nivoom pritiska. Dilatacioni balon za angioplastiku mo\u017ee da se naduva \u010dak i preko 16 atmosfera. (guma na autu se duva na 2 atmosfere). Balon se naj\u010de\u0161\u0107e duva na desetak atmosfera. Pritisak se odr\u017eava nekoliko minuta da bi se pocepani arterioskleoti\u010dni plak zadr\u017eao u dilatiranom polo\u017eaju.Tokom endovaskularne procedure bez<\/b> <\/b>cerebralne<\/b> <\/b>protekcije<\/b> <\/b>postoji velika opasnost od embolizacije distalnih cerebralnih arterija. Protekcija mozga se mo\u017ee izvesti:<\/p>\n

    \n
  • Tehnikom distalne okluzije i<\/li>\n
  • Tehnikom proksimalne okluzije.<\/li>\n<\/ul>\n<\/div>\n
    \n

    PTA<\/b> <\/b>bez<\/b> <\/b>cerebralne<\/b> <\/b>protekcije.<\/b> <\/b>Incidenti tokom endovaskularnih procedura uglavnom se de\u0161avaju zbog embolizacije. PTA sa protektivnim balonom zahteva kateterizaciju arterije (sa mo\u017eda heterogenim plakom ili prizidnom trombozom), upotrebom katetera ve\u0107eg promera. Manipulacija ve\u0107im kateterom na terenu tromboziranog tro\u0161nog plaka stvara mogu\u0107nost za lansiranje embolusa. Argumenti za PTA karotidnih arterija bez protekcije su:
    Kra\u0107e vreme boravka katetera na rizi\u010dnom terenu i
    <\/strong>Kra\u0107a okluzija arterije koja dovodi krv do mozga.<\/strong><\/p>\n<\/div>\n

    \n

    Perkutana transluminalna balon-angioplastika;
    (a) Kroz stenozu se prolazi vodi\u010dem,
    <\/em>(b) Balon-dilatacioni kateter se navodi preko vodi\u010da, kroz stenozu,
    (c) Inflacija balona i <\/em>dilatacija rastezanjem arterije uz utiskivanje nekompresibilnog materijala u arterijski zid,
    (d) Povla\u010denje dilatacionog katetera uz ostavljanje vodi\u010da za kon- trolnu arteriografiju.<\/em><\/p>\n

    \n<\/div>\n

    \"\"<\/p>\n

    \n

    Cerebralna<\/b><\/span> <\/b><\/span>protekcija<\/b><\/span> <\/b><\/span>proksimalnom<\/b><\/span> <\/b><\/span>okluzijom.<\/b><\/span> <\/b><\/span>Protektivni<\/span> <\/span>okluzivni<\/span> <\/span>balon<\/span> <\/span>se<\/span> <\/span>nalazi<\/span> <\/span>proksimalnije<\/span> <\/span>od<\/span> <\/span>balona<\/span> <\/span>za<\/span> <\/span>dilataciju.<\/span> <\/span>In<\/span>fl<\/span>acija<\/span> <\/span>protektivnog<\/span> <\/span>balona<\/span> <\/span>\u0107e<\/span> <\/span>zaustaviti<\/span> <\/span>ortogradni<\/span> <\/span>tok<\/span> <\/span>krvi,<\/span> <\/span>pa<\/span> <\/span>ako<\/span> <\/span>do\u0111e<\/span> <\/span>do<\/span> <\/span>otka\u010dinjanja<\/span> <\/span>emboligenog<\/span> <\/span>materijala,<\/span> <\/span>zbog<\/span> <\/span>retrogradnog<\/span> <\/span>protoka<\/span> <\/span>trebalo<\/span> <\/span>bi<\/span> <\/span>da<\/span> <\/span>distalna<\/span> <\/span>embolizacija<\/span> <\/span>bude<\/span> <\/span>nemogu\u0107a.<\/span> Na <\/span>kraju<\/span> se<\/span> <\/span>debris<\/span> i <\/span>tromboti\u010dki<\/span> <\/span>materijal<\/span> <\/span>ispiraju<\/span> u <\/span>spolja\u0161nju<\/span> <\/span>karotidnu<\/span> <\/span>arteriju.<\/span> <\/span><\/sup>Me\u0111utim,<\/span> <\/span>pitanje<\/span> <\/span>je:<\/span><\/p>\n

      \n
    • Da<\/span> <\/span>li<\/span> <\/span>se<\/span> <\/span>blokiranjem<\/span> <\/span>ortogradnog<\/span> <\/span>protoka<\/span> <\/span>arterije<\/span> <\/span>on<\/span> <\/span>zaista<\/span> <\/span>pretvara<\/span> <\/span>u<\/span> <\/span>retrogradni?<\/span> <\/span>Bo\u010dne<\/span> <\/span>grane<\/span> <\/span>preko<\/span> <\/span>kolateralnog<\/span> <\/span>sistema<\/span> <\/span>mogu<\/span> <\/span>odr\u017eavati,<\/span> <\/span>skroman<\/span> <\/span>ali<\/span> <\/span>dovoljan<\/span> <\/span>otogradni<\/span> <\/span>protok.<\/span><\/li>\n
    • Da<\/span> <\/span>li<\/span> <\/span>\u0107e<\/span> <\/span>broj<\/span> <\/span>ishemi\u010dnih<\/span> <\/span>incidenata<\/span> <\/span>biti<\/span> <\/span>ve\u0107i<\/span> <\/span>jer<\/span> <\/span>se<\/span> <\/span>okludira<\/span> <\/span>zajedni\u010dka<\/span> <\/span>karotidna<\/span> <\/span>arterija,<\/span> <\/span>a<\/span> <\/span>ne<\/span> <\/span>samo<\/span> <\/span>unutra\u0161nja<\/span>?<\/span><\/li>\n
    • \u0160ta<\/span> <\/span>raditi<\/span> <\/span>kod<\/span> <\/span>ostijalnih<\/span> <\/span>stenoza<\/span> <\/span>supraaortalnih<\/span> <\/span>grana?<\/span><\/li>\n
    • Najve\u0107i<\/span> <\/span>problemi<\/span> <\/span>na<\/span> <\/span>koje<\/span> <\/span>se<\/span> <\/span>nailazi<\/span> <\/span>tokom<\/span> <\/span>PTA<\/span> <\/span>sa<\/span> <\/span>protekcijom<\/span> <\/span>mozga<\/span> <\/span>su:<\/span><\/li>\n<\/ul>\n

      Lumen<\/span> <\/span>u<\/span> <\/span>nivou<\/span> <\/span>stenoze<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>suvi\u0161e<\/span> <\/span>tesan<\/span> <\/span>za<\/span> <\/span>prolazak<\/span> <\/span>dvostrukog<\/span> <\/span>balon-<\/span> <\/span>katetera<\/span> <\/span>(balon<\/span> <\/span>za<\/span> <\/span>dilataciju<\/span> <\/span>i<\/span> <\/span>balon<\/span> <\/span>za<\/span> <\/span>protekciju).<\/span><\/p>\n

      Intolerancija<\/span> <\/span>balon<\/span> <\/span>okluzije<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>sa<\/span> <\/span>simptomima<\/span> <\/span>cerebralne<\/span> <\/span>ishemije<\/span> <\/span>javlja<\/span> <\/span>se<\/span> <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>imaju<\/span> <\/span>multiple<\/span> <\/span>stenoti\u010dne<\/span> <\/span>lezije<\/span> <\/span>supraaortalnih<\/span> <\/span>grana<\/span> <\/span>a<\/span> <\/span>imali<\/span> <\/span>su<\/span> <\/span>epizode<\/span> <\/span>TIA.<\/span><\/p>\n

      Pojava<\/span> <\/span>embolizacije<\/span> <\/span>na<\/span> <\/span>transkranijalnom<\/span> <\/span>Doppleru<\/span> <\/span>(<\/span>a.cerebri<\/i><\/span> <\/i><\/span>media<\/i><\/span>)<\/span> <\/span>tokom<\/span> <\/span>ispiranja<\/span> <\/span>unutra\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije,<\/span> <\/span>pre<\/span> <\/span>de<\/span>fl<\/span>acije<\/span> <\/span>protektivnog<\/span> <\/span>balona.<\/span> <\/span>Mogu\u0107e<\/span> <\/span>je<\/span> <\/span>da<\/span> <\/span>(mikro)<\/span> <\/span>embolusi<\/span> <\/span>prolaze<\/span> <\/span>kroz<\/span> <\/span>kolateralne<\/span> <\/span>grane<\/span> <\/span>sistema<\/span> <\/span>spolja\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span><\/p>\n<\/div>\n

      \"\"<\/p>\n

      \n

      Perkutana transluminalna balon-angioplastika;
      (a) Kroz stenozu se prolazi vodi\u010dem, <\/em>(b) Balon-dilatacioni kateter se navodi preko vodi\u010da, kroz stenozu,\u00a0 (c) Inflacija balona i <\/em>dilatacija rastezanjem arterije uz utiskivanje nekompresibilnog materijala u arterijski zid, (d) Povla\u010denje dilatacionog katetera uz ostavljanje vodi\u010da za kon- trolnu arteriografiju.<\/em><\/p>\n

      \n<\/div>\n

      \"\"<\/p>\n

      \n

      Intraproceduralna prevencija cerebralne embolizacije.<\/em><\/p>\n

      \n<\/div>\n

      \"\"<\/p>\n

      \n

      Emboligeni materijal koji se nakupio u protektivnoj <\/em><\/p>\n

      \n<\/div>\n

      \"\"<\/p>\n

      \n

      mre\u017eici pri implantaciji karotidnog stenta.<\/em><\/p>\n

      \n<\/div>\n

      \n

      Implantacija<\/b><\/span> <\/b><\/span>stenta:<\/b><\/span> <\/b><\/span>Stentovi<\/span> <\/span>su<\/span> <\/span>metalni<\/span> <\/span>cilindri<\/span> <\/span>mre\u017easte<\/span> <\/span>strukture,<\/span> <\/span>dizajnirani<\/span> <\/span>tako<\/span> <\/span>da<\/span> <\/span>odr\u017eavju<\/span> <\/span>lumen<\/span> <\/span>arterije<\/span> <\/span>otvorenim<\/span> <\/span>(nakon<\/span> <\/span>dilatacije).<\/span> <\/span>Po\u0161to<\/span> <\/span>je<\/span> <\/span>arterija<\/span> <\/span>pro\u0161irena,<\/span> <\/span>balon-kateter<\/span> <\/span>se<\/span> <\/span>izduva<\/span> <\/span>i<\/span> <\/span>izvadi.<\/span> <\/span>Ako<\/span> <\/span>kontrolna<\/span> <\/span>arteriogra<\/span>fi<\/span>ja<\/span> <\/span>uka\u017ee<\/span> <\/span>na<\/span> <\/span>prisustvo<\/span> <\/span>zna\u010dajne<\/span> <\/span>rezidualne<\/span> <\/span>stenoze<\/span> <\/span>indikovana<\/span> <\/span>je<\/span> <\/span>implantacija<\/span> <\/span>stenta.<\/span> <\/span>Plasira<\/span> <\/span>se<\/span> <\/span>kateter<\/span> <\/span>na<\/span> <\/span>\u010diji<\/span> <\/span>balon<\/span> <\/span>za<\/span> <\/span>dilataciju<\/span> <\/span>je<\/span> <\/span>prethodno<\/span> <\/span>navu\u010den<\/span> <\/span>stent.<\/span> <\/span>Kada<\/span> <\/span>se<\/span> <\/span>polo\u017eaj<\/span> <\/span>stenta,<\/span> <\/span>uz<\/span> <\/span>pomo\u0107<\/span> <\/span>markera<\/span> <\/span>u<\/span> <\/span>balonu<\/span> <\/span>ta\u010dno<\/span> <\/span>odredi<\/span> <\/span>prema<\/span> <\/span>su\u017eenju<\/span> <\/span>koje<\/span> <\/span>\u017eelimo<\/span> <\/span>da<\/span> <\/span>dilatiramo,<\/span> <\/span>balon<\/span> <\/span>se<\/span> <\/span>naduva.<\/span> <\/span>Zajedno<\/span> <\/span>sa<\/span> <\/span>balonom<\/span> <\/span>se<\/span> <\/span>\u0161iri<\/span> <\/span>i<\/span> <\/span>stent.<\/span> <\/span>Kalibar<\/span> <\/span>stenta<\/span> <\/span>je<\/span> <\/span>onaj<\/span> <\/span>koji<\/span> <\/span>ima<\/span> <\/span>maksimalno<\/span> <\/span>rastegnut<\/span> <\/span>balon.<\/span> <\/span>Sada<\/span> <\/span>se<\/span> <\/span>balon<\/span> <\/span>izduva<\/span> <\/span>i<\/span> <\/span>izvu\u010de<\/span> <\/span>a<\/span> <\/span>stent<\/span> <\/span>ostane<\/span> <\/span>utisnut<\/span> <\/span>u<\/span> <\/span>zid<\/span> <\/span>krvnog<\/span> <\/span>suda,<\/span> <\/span>kao<\/span> <\/span>armatura,<\/span> <\/span>koja<\/span> <\/span>dr\u017ei<\/span> <\/span>napukle<\/span> <\/span>delove<\/span> <\/span>zida<\/span> <\/span>arterije<\/span> <\/span>dilatirane.<\/span> <\/span>Ovakva<\/span> <\/span>procedura,<\/span> <\/span>u<\/span> <\/span>dva<\/span> <\/span>akta,<\/span> <\/span>zove<\/span> <\/span>se<\/span> <\/span>\u201c<\/span>sekundarni<\/b><\/span> <\/b><\/span>stenting<\/b><\/span>\u201d.<\/span><\/p>\n

      Procedura<\/span> <\/span>se<\/span> <\/span>mo\u017ee<\/span> <\/span>skratiti<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>na<\/span> <\/span>balonu<\/span> <\/span>kojim<\/span> <\/span>se<\/span> <\/span>dilatira<\/span> <\/span>stenoza<\/span> <\/span>ve\u0107<\/span> <\/span>nalazi<\/span> <\/span>stent,<\/span> <\/span>tako<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>pri<\/span> <\/span>\u0161irenju<\/span> <\/span>krvnog<\/span> <\/span>suda,<\/span> <\/span>istovremeno<\/span> <\/span>postavlja<\/span> <\/span>i<\/span> <\/span>stent.<\/span> <\/span>Ovo<\/span> <\/span>je<\/span> <\/span>\u201c<\/span>primarni<\/b><\/span> <\/b><\/span>stenting<\/b><\/span>\u201d.<\/span> <\/span>Prednost<\/span> <\/span>primarnog stenta<\/span> <\/span>je<\/span> <\/span>redukcija<\/span> <\/span>embolijskog rizika<\/span> <\/span>mozga<\/span> <\/span>zbog<\/span> <\/span>zadr\u017eavanja<\/span> <\/span>emboligenog<\/span> <\/span>materijala<\/span> <\/span>(debris,<\/span> <\/span>tromb)<\/span> <\/span>ispod<\/span> <\/span>stenta<\/span>4<\/span><\/sup>.<\/span> <\/span>To<\/span> <\/span>je<\/span> <\/span>dokazano<\/span> <\/span>primenom<\/span> <\/span>transkranijalnog<\/span> <\/span>Dopplera<\/span> <\/span>tokom<\/span> <\/span>stentinga.<\/span><\/p>\n

      Postoje<\/span> <\/span>dve<\/span> <\/span>vrste<\/span> <\/span>stentova,<\/span> <\/span>prema<\/span> <\/span>na\u010dinu<\/span> <\/span>implantacije:<\/span> <\/span>stent<\/span> <\/span>koji<\/span> <\/span>se<\/span> <\/span>\u0161iri<\/span> <\/span>balonom<\/span> <\/span>(<\/span>Baloon-Expandable<\/i><\/span>)<\/span> <\/span>i<\/span> <\/span>\u201dsamo\u0161ire\u0107i\u201d<\/span> <\/span>stentovi<\/span> <\/span>(<\/span>Self-Expandable<\/i><\/span>).<\/span><\/p>\n

      Dve<\/span> <\/span>mogu\u0107nosti<\/span> <\/span>za<\/span> <\/span>plasiranje<\/span> <\/span>stenta:<\/span><\/p>\n

        \n
      • Primarni<\/b><\/span> <\/b><\/span>stenting<\/b><\/span> <\/b><\/span>je<\/span> <\/span>plasiranje<\/span> <\/span>(<\/span>deployment<\/i><\/span>)<\/span> <\/span>stenta,<\/span> <\/span>a<\/span> <\/span>zatim<\/span> <\/span>dilatacija<\/span> <\/span>stenoze<\/span> <\/span>balonom<\/span> <\/span>preko<\/span> <\/span>stenta.<\/span><\/li>\n
      • Sekundarni<\/b><\/span> <\/b><\/span>stenting<\/b><\/span> <\/b><\/span>za\u010di<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>prvo<\/span> <\/span>uradi<\/span> <\/span>endoluminalna<\/span> <\/span>dilatacija.<\/span> <\/span>Ako<\/span> <\/span>zaostane<\/span> <\/span>rezidualna<\/span> <\/span>stenoza<\/span> <\/span>ili<\/span> <\/span>intimalni<\/span> <\/span>fl<\/span>ap<\/span> <\/span>plasira<\/span> <\/span>se<\/span> <\/span>stent.<\/span><\/li>\n<\/ul>\n

        Pod<\/span> <\/span>pritiskom<\/span> <\/span>naduvanog<\/span> <\/span>balona<\/span> <\/span>dolazi<\/span> <\/span>do<\/span> <\/span>sabijanja<\/span> <\/span>plaka,<\/span> <\/span>ili<\/span> <\/span>do<\/span> <\/span>prskanja<\/span> <\/span>kontinuiteta<\/span> <\/span>prstenastog<\/span> <\/span>plaka,<\/span> <\/span>uz<\/span> <\/span>disekciju<\/span> <\/span>zida<\/span> <\/span>arterije.<\/span> <\/span>Kod<\/span> <\/span>disekcije<\/span> <\/span>prska<\/span> <\/span>i<\/span> <\/span>medija,<\/span> <\/span>a<\/span> <\/span>cirkuli\u0161u\u0107a<\/span> <\/span>krv<\/span> <\/span>dolazi<\/span> <\/span>do<\/span> <\/span>adventicije<\/span> <\/span>dilatiranog<\/span> <\/span>krvnog<\/span> <\/span>suda,<\/span> <\/span>\u0161to<\/span> <\/span>stvara<\/span> <\/span>mogu\u0107nost<\/span> <\/span>za<\/span> <\/span>prizidnu<\/span> <\/span>trombozu.<\/span> <\/span>Rezidualna<\/span> <\/span>stenoza,<\/span> <\/span>disekcija<\/span> <\/span>i<\/span> <\/span>manje<\/span> <\/span>neravnine<\/span> <\/span>na<\/span> <\/span>mestu<\/span> <\/span>dilatacije<\/span> <\/span>uzrokuju<\/span> <\/span>turbulenciju<\/span> <\/span>krvi<\/span> <\/span>koja<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>uzrok<\/span> <\/span>komplikacija.<\/span><\/p>\n

          \n
        • Rane<\/b><\/span> <\/b><\/span>komplikacije<\/b><\/span> <\/b><\/span>su<\/span> <\/span>disekcija,<\/span> <\/span>akutna<\/span> <\/span>prizidna<\/span> <\/span>tromboza<\/span> <\/span>i<\/span> <\/span>akutna<\/span> <\/span>tromboti\u010dna<\/span> <\/span>okluzija<\/span> <\/span>tek<\/span> <\/span>dilatirane<\/span> <\/span>arterije.<\/span><\/li>\n
        • Kasne<\/b><\/span> <\/b><\/span>komplikacije<\/b><\/span> <\/b><\/span>su<\/span> <\/span>proliferacija<\/span> <\/span>intime<\/span> <\/span>i<\/span> <\/span>fi<\/span>broznog<\/span> <\/span>tkiva<\/span> <\/span>sa<\/span> <\/span>nastankom<\/span> <\/span>restenoze,<\/span> <\/span>neointimalne<\/span> <\/span>hiperplazije,<\/span> <\/span>progresije<\/span> <\/span>bolesti,<\/span> <\/span>reokluzija<\/li>\n<\/ul>\n

          Stent karotidna angioplastika se pojavljuje kao potencijalna alternativa za karotidnu endarterektomiju. Endovaskularne procedure mogu imati prednost u slu\u010daju pacijenata sa velikim op\u0161tim rizikom, koronarnom bole\u0161\u0107u, kao i simultanim lezijama vi\u0161e arterija koje dovode krv do mozga. Prednost bi moglo biti izbegavanje lezija kranijalnih nerava, koje se kod karotidne endarterektomije, dodu\u0161e kao privremeni problem javljaju u oko 7% slu\u010dajeva.<\/p>\n

          Formiraju<\/span> <\/span>se<\/span> <\/span>multi-disciplinarni<\/span> <\/span>timovi<\/span> <\/span>koji<\/span> <\/span>uklju\u010duju:<\/span> <\/span>neurologa,<\/span> <\/span>angiologa,<\/span> <\/span>neuro-radiologa,<\/span> <\/span>vaskularnog<\/span> <\/span>hirurga<\/span> <\/span>i<\/span> <\/span>intervencionistu<\/span> <\/span>(radiolog<\/span> <\/span>i<\/span> <\/span>vaskularni<\/span> <\/span>hirurg<\/span> <\/span>izvode<\/span> <\/span>edovaskularne<\/span> <\/span>intervencije).<\/span><\/p>\n

          Karotidna<\/span> <\/span>endarterektomija<\/span> <\/span>(CEA)<\/span> <\/span>je<\/span> <\/span>pouzdan<\/span> <\/span>i<\/span> <\/span>efektivan<\/span> <\/span>tretman<\/span> <\/span>simptomatske<\/span> <\/span>i<\/span> <\/span>asimptomatske<\/span> <\/span>stenoze<\/span> <\/span>karotidnih<\/span> <\/span>arterija.<\/span> <\/span><\/sup>Tokom<\/span> <\/span>poslednje<\/span> <\/span>decenije<\/span> <\/span>endovaskularni<\/span> <\/span>tretman<\/span> <\/span>sa<\/span> <\/span>stentiranjem<\/span> <\/span>(CAS)<\/span> <\/span>pojavio<\/span> <\/span>se<\/span> <\/span>kao<\/span> <\/span>alteranativa<\/span> <\/span>karotidnoj<\/span> <\/span>endarterektomiji.<\/span><\/p>\n

          Dobre<\/span> <\/span>strane<\/span> <\/span>karotidne<\/span> <\/span>stent-angioplastke<\/span> <\/span>su:<\/span><\/strong><\/p>\n

            \n
          • mogu\u0107nost<\/span> <\/span>primene<\/span> <\/span>neposredno<\/span> <\/span>pre<\/span> <\/span>i\/ili<\/span> <\/span>posle<\/span> <\/span>drugih<\/span> <\/span>velikih<\/span> <\/span>operacija<\/span> <\/span>(koronarna<\/span> <\/span>revaskularizacija),<\/span><\/li>\n
          • mogu\u0107nost<\/span> <\/span>endovaskularne<\/span> <\/span>intervencije<\/span> <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>sa<\/span> <\/span>te\u0161kim<\/span> <\/span>koronarnim<\/span> <\/span>lezijama,<\/span><\/li>\n
          • re\u0161avanje<\/span> <\/span>restenoza<\/span> <\/span>nakon<\/span> <\/span>karotidne<\/span> <\/span>endarterektomije,<\/span><\/li>\n
          • korekcije<\/span> <\/span>hirur\u0161ki<\/span> <\/span>nepristupa\u010dnih<\/span> <\/span>lezija<\/span> <\/span>(visoke<\/span> <\/span>tandem<\/span> <\/span>lezije),<\/span><\/li>\n
          • mogu\u0107a<\/span> <\/span>primena<\/span> <\/span>kod<\/span> <\/span>fi<\/span>bromuskularne<\/span> <\/span>displazije,<\/span> <\/span>arteritisa<\/span> <\/span>i<\/span> <\/span>postiradijacionog<\/span> <\/span>arteritisa.<\/span><\/li>\n<\/ul>\n<\/div>\n

            \"\"<\/p>\n

            \n

            Perkutana transluminalna angioplastika sa stentom zbog ateroskleroti\u010dne stenoze (90%) desne subklavijalne i desne vertebralne arterije<\/em><\/p>\n<\/div>\n

            \"\"<\/p>\n

            \n

            Dislokacija ateroskleroti\u010dnog plaka pri implantaciji aortnog stent grafta, sa stenozom leve <\/em>zajedni\u010dke karotidne arterije u koju je transponirana leva subklavijalna arterija u sklopu hybrid procedure.<\/em><\/p>\n<\/div>\n

            \"\"<\/p>\n

            \n

            Dilatacija orificijuma leve zajedni\u010dke arterije sa implantacijom stenta.<\/em><\/p>\n<\/div>\n

            \n

            Limitiraju\u0107i<\/span> <\/span>faktore<\/span> <\/span>karotidne<\/span> <\/span>angioplastike<\/span>:<\/span><\/strong><\/p>\n

              \n
            • Lo\u0161i<\/span> <\/span>rezultati<\/span> <\/span>u<\/span> <\/span>bolestnika<\/span> <\/span>starijih<\/span> <\/span>od<\/span> <\/span>70<\/span> <\/span>god.<\/span><\/li>\n
            • Nije<\/span> <\/span>mogu\u0107a<\/span> <\/span>PTA<\/span> <\/span>okluzivnih<\/span> <\/span>lezija,<\/span><\/li>\n
            • PTA<\/span> <\/span>ulcerisanog<\/span> <\/span>(nestabilno)<\/span> <\/span>plaka<\/span> <\/span>ima<\/span> <\/span>veliki<\/span> <\/span>rizik<\/span> <\/span>od<\/span> <\/span>embolizacije,<\/span><\/li>\n
            • PTA<\/span> <\/span>ekscentri\u010dnog<\/span> <\/span>kalcifkovanog<\/span> <\/span>plaka<\/span> <\/span>daje<\/span> <\/span>lo\u0161e<\/span> <\/span>rezultate,<\/span><\/li>\n
            • Koegzistiraju\u0107i<\/span> <\/span>kinking,<\/span><\/em> <\/i><\/span>coiling<\/i><\/span> <\/i><\/span>i<\/span> <\/span>aneurizma<\/span> <\/span>se<\/span> <\/span>ne<\/span> <\/span>mogu<\/span> <\/span>otkloniti<\/span> <\/span>PTA.<\/span><\/li>\n<\/ul>\n

              V<\/span>elik<\/span>e<\/span> <\/span>prospektivn<\/span>e<\/span> <\/span>randomizovan<\/span>e<\/span> <\/span>klini\u010dk<\/span>e<\/span> <\/span>studij<\/span>e<\/span> <\/span>(C<\/span>AV<\/span>A<\/span>T<\/span>AS<\/span>,<\/span> <\/span>SAPPHIRE<\/span>,<\/span> <\/span>E<\/span>V<\/span>A-3S<\/span>,<\/span> <\/span>S<\/span>P<\/span>ACE<\/span>,<\/span> <\/span>ICS<\/span>S<\/span> <\/span>i<\/span> <\/span>druge<\/span>)<\/span> <\/span>s<\/span>u<\/span> <\/span>poredil<\/span>e<\/span> <\/span>rezultat<\/span>e<\/span> <\/span>CE<\/span>A<\/span> <\/span>i<\/span> <\/span>CAS<\/span>.<\/span><\/p>\n

              Rezultati<\/span> <\/span>studija<\/span> <\/span>uglavnom<\/span> <\/span>favorizuju<\/span> <\/span>karotidnu<\/span> <\/span>endarterektomiju<\/span> <\/span>kao<\/span> <\/span>metodu<\/span> <\/span>izbora<\/span> <\/span>u<\/span> <\/span>le\u010denju<\/span> <\/span>karotidne<\/span> <\/span>stenoze<\/span> <\/span>osim,<\/span> <\/span>u<\/span> <\/span>posebnim<\/span> <\/span>slu\u010dajevima,<\/span> <\/span>\u0161to<\/span> <\/span>je<\/span> <\/span>prikazano<\/span> <\/span>u<\/span> <\/span>\u201eESVS<\/span> <\/span>guidelines\u201c<\/span> <\/span>i<\/span> <\/span>\u201eSVS<\/span> <\/span>guidelines\u201c<\/span> <\/span>za<\/span> <\/span>le\u010denje<\/span> <\/span>karotidne<\/span> <\/span>stenoze.<\/span><\/p>\n

              V<\/span>e\u0107in<\/span>a<\/span> <\/span>autor<\/span>a<\/span> <\/span>rezultat<\/span>e<\/span> <\/span>C<\/span>AV<\/span>A<\/span>T<\/span>A<\/span>S<\/span> <\/span>(<\/span>C<\/b><\/span>aroti<\/span>d<\/span> <\/span>A<\/b><\/span>n<\/span>d<\/span> <\/span>V<\/b><\/span>ertebra<\/span>l<\/span> <\/span>A<\/b><\/span>rter<\/span>y<\/span> <\/span>T<\/b><\/span>ranslumina<\/span>l<\/span> <\/span>A<\/b><\/span>ngioplasty<\/span> <\/span>S<\/b><\/span>tudy)<\/span> <\/span>studije<\/span> <\/span>zavr\u0161ene<\/span> <\/span>2001.<\/span> <\/span>godine<\/span> <\/span>danas<\/span> <\/span>ne<\/span> <\/span>uklju\u010duje<\/span> <\/span>u<\/span> <\/span>analize.<\/span> <\/span>Naime,<\/span> <\/span>samo<\/span> <\/span>26%<\/span> <\/span>pacijenata<\/span> <\/span>koji<\/span> <\/span>su<\/span> <\/span>randomizovani<\/span> <\/span>za<\/span> <\/span>endovaskularni<\/span> <\/span>tretman<\/span> <\/span>j<\/span>e<\/span> <\/span>stentirano<\/span>.<\/span> <\/span>V<\/span>e\u0107in<\/span>a<\/span> <\/span>pacijenat<\/span>a<\/span> <\/span>j<\/span>e<\/span> <\/span>tretiran<\/span>a<\/span> <\/span>sam<\/span>o<\/span> <\/span>balo<\/span>n<\/span> <\/span>angioplastikom<\/span>,<\/span> <\/span>\u0161t<\/span>o<\/span> <\/span>ne<\/span> <\/span>odgovara<\/span> <\/span>savremenim<\/span> <\/span>standardima<\/span> <\/span>endovaskularnog<\/span> <\/span>tretmana<\/span> <\/span>karotidne<\/span> <\/span>stenoze.<\/span><\/p>\n

              SAPPHIRE<\/span><\/strong> <\/span>(<\/span>S<\/b><\/span>tenting<\/span> <\/span>and<\/span> <\/span>A<\/b><\/span>ngioplasty<\/span> <\/span>with<\/span> <\/span>P<\/b><\/span>rotection<\/span> <\/span>in<\/span> <\/span>P<\/b><\/span>atients<\/span> <\/span>at<\/span> <\/span>H<\/b><\/span>igh<\/span> <\/span>R<\/b><\/span>isk<\/span> <\/span>for<\/span> <\/span>E<\/b><\/span>ndarterectomy)<\/span> <\/span>studija<\/span> <\/span>je<\/span> <\/span>publikovana<\/span> <\/span>2004.<\/span> <\/span>Ovo<\/span> <\/span>je<\/span> <\/span>jedina<\/span> <\/span>me\u0111u<\/span> <\/span>navedenim<\/span> <\/span>studijama<\/span> <\/span>koja<\/span> <\/span>je<\/span> <\/span>pokazala<\/span> <\/span>da<\/span> <\/span>CAS<\/span> <\/span>nije<\/span> <\/span>inferioran<\/span> <\/span>u<\/span> <\/span>odnosu<\/span> <\/span>na<\/span> <\/span>CEA<\/span> <\/span>u<\/span> <\/span>le\u010denju<\/span> <\/span>karotidne<\/span> <\/span>stenoze.<\/span>12<\/span><\/sup> <\/span><\/sup>U<\/span> <\/span>studiju<\/span> <\/span>je<\/span> <\/span>uklju\u010deno<\/span> <\/span>334<\/span> <\/span>pacijenta<\/span> <\/span>u<\/span> <\/span>28<\/span> <\/span>ustanova,<\/span> <\/span>sa<\/span> <\/span>stenozom<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>i<\/span> <\/span>visokim<\/span> <\/span>rizikom<\/span> <\/span>za<\/span> <\/span>operativno<\/span> <\/span>le\u010denje.<\/span> <\/span>Glavni<\/span> <\/span>razlozi<\/span> <\/span>visoko<\/span>g<\/span> <\/span>rizik<\/span>a<\/span> <\/span>s<\/span>u<\/span> <\/span>bil<\/span>i<\/span> <\/span>koronarn<\/span>a<\/span> <\/span>boles<\/span>t<\/span> <\/span>i<\/span> <\/span>staros<\/span>t<\/span> <\/span>prek<\/span>o<\/span> <\/span>8<\/span>0<\/span> <\/span>godina<\/span>.<\/span> <\/span>V<\/span>e\u0107in<\/span>a<\/span> <\/span>(71%<\/span>)<\/span> <\/span>uklju\u010denih<\/span> <\/span>pacijenata<\/span> <\/span>bili<\/span> <\/span>su<\/span> <\/span>asimptomati\u010dni.<\/span> <\/span>Danas<\/span> <\/span>se<\/span> <\/span>smatra<\/span> <\/span>da<\/span> <\/span>uklju\u010divanje<\/span> <\/span>samo<\/span> <\/span>asimptomatskih,<\/span> <\/span>visoko<\/span> <\/span>rizi\u010dnih<\/span> <\/span>pacijenata<\/span> <\/span>dovodi<\/span> <\/span>do<\/span> <\/span>pristrasnosti<\/span> <\/span>(\u201e<\/span>bias<\/i><\/span>\u201c)<\/span> <\/span>u<\/span> <\/span>studijskom<\/span> <\/span>dizajnu.<\/span><\/p>\n

              EVA-3S<\/strong> (E<\/b>ndarterectomy V<\/b>ersus A<\/b>ngioplasty in S<\/b>ymptomatic S<\/b>evere carotis S<\/b>tenosis) studija uklju\u010dila je 527 pacijenata sa visokostepenom simptomatskom stenozom u 30 centara u Francuskoj. Rezultati su publikovani 2006. U\u010destalost neurolo\u0161kih komplikacija u grupi randomizovanoj za CAS bila je vi\u0161e nego dva puta ve\u0107a nego u CEA grupi (9,6% prema 3,9%) zbog \u010dega je studija prekinuta, iako je planirano uklju\u010denje oko 4000 pacijenta. <\/span><\/sup>Istra\u017eiva\u010di uklju\u010deni u studiju nastavili su pra\u0107enje pacijenata i publikovanje dugoro\u010dnih rezultata.<\/p>\n

              U SPACE<\/strong> (S<\/b>tent-supported P<\/b>ercutaneous A<\/b>ngioplasty of the C<\/b>arotid artery versus E<\/b>ndarterectomy) studiju uklju\u010deno je 1200 simptomatskih pacijenta u 35 centara u \u0160vajcarskoj, Austriji i Nema\u010dkoj. Rezultati su publikovani 2006. <\/span><\/sup>Kao i kod EVA-3S, rezultali su favorizovali CEA kao metodu izbora u le\u010denju karotidne stenoze u ve\u0107ini klini\u010dkih situacija. Ova studija je, statisti\u010dki slaba za dono\u0161enje definitivnih zaklju\u010daka, jer je kao i prethodne prekinuta ranije. Iako je embolijska protekcija preporu\u010dena, ona je upotrebljena kod manjeg broja pacijenata.<\/p>\n

              Rezultati ICSS<\/strong> (I<\/b>nternational C<\/b>arotid S<\/b>tenting S<\/b>tudy) studije publikovani su u martu 2010. Ova studija uklju\u010dila je 1713 simptomatskih pacijenata i to 855 randomizovanih za CAS i 858 randomizovanih za CEA. U periodu od randomizacije i pra\u0107enja od 120 dana bilo je 4% infarkta mozga sa invaliditetom ili smrti u CAS grupi, prema 3,2% u CEA grupi. Incidenca infarkta mozga, smrti ili infarkta miokarda bila je 8,5% u CAS grupi, u poredjenju sa 5,2% u CEA grupi (p=0.006). Studija je pokazala da CEA treba da ostane tretman izbora za pacijente bez povi\u0161enog hirur\u0161kog rizika.<\/p>\n

              Met<\/b>a<\/b> <\/b>analiz<\/b>a<\/b>. Istra\u017eiva\u010di iz EVA-3S, SPACE i ICSS studija su, prema prethodno postignutom dogovoru, publikovali rezultate metaanalize ukupnog broja pacijenata uklju\u010denih u ove tri studije.8,13<\/span><\/sup> <\/span><\/sup>Rezultati uklju\u010duju analizu podataka 30 dana nakon randomizacije (per protokol (PP) analysis) i 120 dana nakon randomizacije (intention to treat (ITT) analysis). Analiza uklju\u010duje ukupno 3433 pacijenta.<\/p>\n

              Rizik od infarkta mozga ili smrtnog ishoda ve\u0107i je u CAS nego u CEA grupi. Ova razlika poti\u010de pre svega od razlike u u\u010destalosti manjih infarkta mozga, bez invaliditeta (non<\/i> <\/i>disabling<\/i> <\/i>stroke<\/i>) koja je duplo ve\u0107a u CAS nego u CEA grupi. U korist hirurgije govori i u\u010destalost pojave infarkta mozga sa invaliditetom ili smrti (disabling<\/i> <\/i>stroke<\/i> <\/i>or<\/i> <\/i>death<\/i>). Infarkt miokarda je redak i javlja se \u010de\u0161\u0107e u CEA grupi. Pojava hematoma na vratu posle CEA \u010de\u0161\u0107a je od pojave hematoma u preponi nakon CAS.<\/p>\n

              Zna\u010dajna interakcija prime\u0107ena je izme\u0111u starosti pacijenata i pojave komplikacija. Rizik pojave infarkta mozga ili smrti u pacijenata starijih od 70 godina je dvostruko ve\u0107i u CAS grupi. Sli\u010dna pojava zabele\u017eena je i u svakoj studiji pojedina\u010dno, iako je interakcija zna\u010dajna samo u SPACE studiji. Ovi rezultati uklju\u010deni su u aktuelne vodi\u010de za le\u010denje karotidne bolesti.<\/p>\n

              Rezultati meta analize potvr\u0111uju prethodne stavove o CEA kao metodi izbora u le\u010denju simptomatske karotidne stenoze, uz CAS kao metodu rezervisanu za simptomatske pacijente rizi\u010dne za hirurgiju, recidive stenoza nakon CEA i stenoze nakon zra\u010denja.<\/p>\n

              CREST<\/span> <\/span><\/strong>(<\/span>C<\/b><\/span>arotid<\/span> <\/span>R<\/b><\/span>evascularisation<\/span> <\/span>E<\/b><\/span>ndarterectomy<\/span> <\/span>vs.<\/span> <\/span>S<\/b><\/span>tenting<\/span> <\/span>T<\/b><\/span>rial)<\/span> <\/span>studija,<\/span> <\/span>poslednja<\/span> <\/span>me\u0111u<\/span> <\/span>studijama<\/span> <\/span>koje<\/span> <\/span>porede<\/span> <\/span>CAS<\/span> <\/span>i<\/span> <\/span>CEA,<\/span> <\/span>publikovana<\/span> <\/span>je<\/span> <\/span>jula<\/span> <\/span>2010.<\/span> <\/span>Studija<\/span> <\/span>je<\/span> <\/span>sprovedena<\/span> <\/span>u<\/span> <\/span>108<\/span> <\/span>centara<\/span> <\/span>u<\/span> <\/span>SAD<\/span> <\/span>i<\/span> <\/span>9<\/span> <\/span>centara<\/span> <\/span>u<\/span> <\/span>Kanadi.<\/span> <\/span>Serti<\/span>fi<\/span>kaciju<\/span> <\/span>za<\/span> <\/span>u\u010de\u0161\u0107e<\/span> <\/span>dobilo<\/span> <\/span>je<\/span> <\/span>477<\/span> <\/span>hirurga<\/span> <\/span>(uslov:<\/span> <\/span>vi\u0161e<\/span> <\/span>od<\/span> <\/span>12<\/span> <\/span>procedura<\/span> <\/span>godi\u0161nje<\/span> <\/span>sa<\/span> <\/span>manje<\/span> <\/span>od<\/span> <\/span>3%<\/span> <\/span>komplikacija<\/span> <\/span>i<\/span> <\/span>smrti<\/span> <\/span>za<\/span> <\/span>asimptomatske<\/span> <\/span>i<\/span> <\/span>manje<\/span> <\/span>od<\/span> <\/span>5%<\/span> <\/span>za<\/span> <\/span>simptomatske<\/span> <\/span>pacijente)<\/span> <\/span>i<\/span> <\/span>224<\/span> <\/span>interventnih<\/span> <\/span>specijalista<\/span> <\/span>serti<\/span>fi<\/span>kovanih<\/span> <\/span>u<\/span> <\/span>odnosu<\/span> <\/span>na<\/span> <\/span>broj<\/span> <\/span>i<\/span> <\/span>rezultate<\/span> <\/span>prethodnih<\/span> <\/span>CAS.<\/span> <\/span>Kori\u0161\u0107ena<\/span> <\/span>je<\/span> <\/span>jedna<\/span> <\/span>vrsta<\/span> <\/span>stentova<\/span> <\/span>i<\/span> <\/span>jedna<\/span> <\/span>vrsta<\/span> <\/span>protektivnih<\/span> <\/span>fi<\/span>ltera.<\/span>15<\/span><\/sup> <\/span><\/sup>U<\/span> <\/span>studiju<\/span> <\/span>je<\/span> <\/span>uklju\u010deno<\/span> <\/span>2502<\/span> <\/span>simptomatska<\/span> <\/span>i<\/span> <\/span>asimptomatska<\/span> <\/span>pacijenta<\/span> <\/span>koji<\/span> <\/span>su<\/span> <\/span>randomizovani<\/span> <\/span>u<\/span> <\/span>CAS<\/span> <\/span>grupu<\/span> <\/span>(1262<\/span> <\/span>pacijenta)<\/span> <\/span>i<\/span> <\/span>CEA<\/span> <\/span>grupu<\/span> <\/span>(1240<\/span> <\/span>pacijenata).<\/span> <\/span>Primarni<\/span> <\/span>ne\u017eeljeni<\/span> <\/span>doga\u0111aj<\/span> <\/span>koji<\/span> <\/span>je<\/span> <\/span>pra\u0107en<\/span> <\/span>bio<\/span> <\/span>je<\/span> <\/span>infarkt<\/span> <\/span>mozga,<\/span> <\/span>infarkt<\/span> <\/span>miokarda<\/span> <\/span>ili<\/span> <\/span>smrt<\/span> <\/span>tokom<\/span> <\/span>periproceduralnog<\/span> <\/span>perioda,<\/span> <\/span>kao<\/span> <\/span>i<\/span> <\/span>tokom<\/span> <\/span>4<\/span> <\/span>godine<\/span> <\/span>nakon<\/span> <\/span>randomizacije.<\/span> <\/span>Sekundarni<\/span> <\/span>cilj<\/span> <\/span>bio<\/span> <\/span>je<\/span> <\/span>procena<\/span> <\/span>efekta<\/span> <\/span>tretmana<\/span> <\/span>u<\/span> <\/span>odnosu<\/span> <\/span>na<\/span> <\/span>simptomatski<\/span> <\/span>status,<\/span> <\/span>pol<\/span> <\/span>i<\/span> <\/span>starost.<\/span> <\/span>CAS<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>96,1%<\/span> <\/span>slu\u010dajeva<\/span> <\/span>sproveden<\/span> <\/span>uz<\/span> <\/span>embolijsku<\/span> <\/span>protekciju.<\/span>15<\/span><\/sup> <\/span><\/sup>Tokom<\/span> <\/span>postproceduralnog<\/span> <\/span>perioda<\/span> <\/span>(30<\/span> <\/span>dana<\/span> <\/span>od<\/span> <\/span>procedure)<\/span> <\/span>incidencija<\/span> <\/span>primarnog<\/span> <\/span>ne\u017eeljenog<\/span> <\/span>doga\u0111aja<\/span> <\/span>bila<\/span> <\/span>je<\/span> <\/span>5,2%<\/span> <\/span>u<\/span> <\/span>CAS<\/span> <\/span>grupi<\/span> <\/span>i<\/span> <\/span>4,5%<\/span> <\/span>u<\/span> <\/span>CEA<\/span> <\/span>grupi,<\/span> <\/span>iako<\/span> <\/span>se<\/span> <\/span>u\u010destalost<\/span> <\/span>pojedina\u010dnih<\/span> <\/span>doga\u0111aja<\/span> <\/span>razlikovala<\/span> <\/span>izmedju<\/span> <\/span>grupa:<\/span> <\/span>smrt<\/span> <\/span>0,7%<\/span> <\/span>prema<\/span> <\/span>0,3%,<\/span> <\/span>(p=0,18);<\/span> <\/span>infarkt<\/span> <\/span>mozga<\/span> <\/span>4,1%<\/span> <\/span>prema<\/span> <\/span>2,3%,<\/span> <\/span>(p=0,01);<\/span> <\/span>infarkt<\/span> <\/span>miokarda<\/span> <\/span>1,1%<\/span> <\/span>prema<\/span> <\/span>2,3%<\/span> <\/span>(p=0,03).<\/span> <\/span>Procenjena<\/span> <\/span>incidencija<\/span> <\/span>primarnog<\/span> <\/span>ne\u017eeljenog<\/span> <\/span>doga\u0111aja<\/span> <\/span>nakon<\/span> <\/span>4<\/span> <\/span>godine<\/span> <\/span>se<\/span> <\/span>ne<\/span> <\/span>razlikuje<\/span> <\/span>izme\u0111u<\/span> <\/span>grupa<\/span> <\/span>(<\/span> <\/span>CAS<\/span> <\/span>7,2%,<\/span> <\/span>CEA<\/span> <\/span>6,8%).<\/span><\/p>\n

              Detektovana<\/span> <\/span>je<\/span> <\/span>interakcija<\/span> <\/span>izme\u0111u<\/span> <\/span>starosti<\/span> <\/span>i<\/span> <\/span>efekta<\/span> <\/span>tretmana,<\/span> <\/span>sa<\/span> <\/span>granicom<\/span> <\/span>na<\/span> <\/span>70<\/span> <\/span>godina<\/span> <\/span>starosti.<\/span> <\/span>CAS<\/span> <\/span>je<\/span> <\/span>e<\/span>fi<\/span>kasniji<\/span> <\/span>kod<\/span> <\/span>mla\u0111ih<\/span> <\/span>pacijenata,<\/span> <\/span>a<\/span> <\/span>CEA<\/span> <\/span>kod<\/span> <\/span>starijih.<\/span>8<\/span><\/sup> <\/span><\/sup>Kada<\/span> <\/span>se<\/span> <\/span>posmatra<\/span> <\/span>samo<\/span> <\/span>grupa<\/span> <\/span>asimptomatskih<\/span> <\/span>pacijenata,<\/span> <\/span>incidenca<\/span> <\/span>infarkta<\/span> <\/span>mozga<\/span> <\/span>i<\/span> <\/span>smrti<\/span> <\/span>nakon<\/span> <\/span>CAS<\/span> <\/span>bila<\/span> <\/span>je<\/span> <\/span>2,5%<\/span> <\/span>,<\/span> <\/span>a<\/span> <\/span>nakon<\/span> <\/span>CEA<\/span> <\/span>1,4%,<\/span> <\/span>\u0161to<\/span> <\/span>je<\/span> <\/span>ni\u017ee<\/span> <\/span>nego<\/span> <\/span>u<\/span> <\/span>prethodno<\/span> <\/span>publikovanim<\/span> <\/span>studijama.<\/span>15<\/span><\/sup> <\/span><\/sup>CREST<\/span> <\/span>studija<\/span> <\/span>publikuje<\/span> <\/span>rezultate<\/span> <\/span>koji<\/span> <\/span>su<\/span> <\/span>najbolji<\/span> <\/span>od<\/span> <\/span>svih<\/span> <\/span>dosada\u0161njih<\/span> <\/span>randomizovanih<\/span> <\/span>kontrolisanih<\/span> <\/span>studija<\/span> <\/span>i<\/span> <\/span>za<\/span> <\/span>endovaskularni<\/span> <\/span>i<\/span> <\/span>hirur\u0161ki<\/span> <\/span>tretman<\/span> <\/span>karotidne<\/span> <\/span>bolesti.<\/span> <\/span>To<\/span> <\/span>ukazuje<\/span> <\/span>na<\/span> <\/span>napretke<\/span> <\/span>vaskularne<\/span> <\/span>i<\/span> <\/span>endovaskularne<\/span> <\/span>tehnologije.<\/span><\/p>\n

              Stariji<\/span> <\/span>pacijenti<\/span> <\/span>imaj<\/span>u<\/span> bolj<\/span>i <\/span>isho<\/span>d <\/span>nako<\/span>n<\/span> <\/span>CE<\/span>A <\/span>neg<\/span>o <\/span>nako<\/span>n<\/span> <\/span>CAS.<\/span> <\/span>Pove\u0107an<\/span>i<\/span>rizi<\/span>k<\/span>o<\/span>d<\/span> <\/span>CAS<\/span> <\/span>kod<\/span> <\/span>starijih<\/span> <\/span>pacijenata<\/span> <\/span>verovatno<\/span> <\/span>je<\/span> <\/span>povezan,<\/span> <\/span>sa<\/span> <\/span>izra\u017eenijom<\/span> <\/span>aterosklerozom<\/span> <\/span>luka<\/span> <\/span>aorte,<\/span> <\/span>ve\u0107om<\/span> <\/span>vulnerabilno\u0161\u0107u<\/span> <\/span>plaka,<\/span> <\/span>tortuozitetom<\/span> <\/span>i<\/span> <\/span>izra\u017eenim<\/span> <\/span>kalci<\/span>fi<\/span>katima<\/span> <\/span>na<\/span> <\/span>krvnim<\/span> <\/span>sudovima.<\/span><\/p>\n<\/div>\n

              \n

              Incidencija<\/span> <\/span>infarkta<\/span> <\/span>mozga<\/span> <\/span>tokom<\/span> <\/span>procedure<\/span> <\/span>ve\u0107a<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>CAS<\/span> <\/span>grupi,<\/span> <\/span>dok<\/span> <\/span>je<\/span> <\/span>incidenca<\/span> <\/span>infarkta<\/span> <\/span>miokarda<\/span> <\/span>ve\u0107a<\/span> <\/span>u<\/span> <\/span>CEA<\/span> <\/span>grupi.<\/span>15<\/span><\/sup> <\/span><\/sup>Ograni\u010denja<\/span> <\/span>studije<\/span> <\/span>su<\/span> <\/span>prvo<\/span> <\/span>serti<\/span>fi<\/span>kacija,<\/span> <\/span>koja<\/span> <\/span>za<\/span> <\/span>posledicu<\/span> <\/span>ima<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>rezultati<\/span> <\/span>najverovatnije<\/span> <\/span>mogu<\/span> <\/span>primeniti<\/span> <\/span>samo<\/span> <\/span>na<\/span> <\/span>sli\u010dno<\/span> <\/span>kvali<\/span>fi<\/span>kovane<\/span> <\/span>operatore.<\/span> <\/span>Upotreba<\/span> <\/span>samo<\/span> <\/span>jedne<\/span> <\/span>vrste<\/span> <\/span>stent<\/span> <\/span>sistema<\/span> <\/span>limitira<\/span> <\/span>primenu<\/span> <\/span>rezultata<\/span> <\/span>na<\/span> <\/span>druge<\/span> <\/span>sisteme.<\/span> <\/span>Studija<\/span> <\/span>nije<\/span> <\/span>uklju\u010divala<\/span> <\/span>grupu<\/span> <\/span>medikamentozno<\/span> <\/span>le\u010denih,<\/span> <\/span>\u0161to<\/span> <\/span>spre\u010dava<\/span> <\/span>generalizaciju<\/span> <\/span>rezltata.<\/span><\/p>\n

              Rezultati do sad publikovanih randomizovanih kontrolisanih studija koje su poredile CAS i CEA uklonili su CAS iz fokusa tretmana karotidne stenoze. Entuzijazam vezan za interventno le\u010denje karotidne bolesti.<\/p>\n

              Rezultati<\/span> <\/span>do<\/span> <\/span>sada<\/span> <\/span>publikovanih<\/span> <\/span>randomizovanih<\/span> <\/span>kontrolisanih<\/span> <\/span>studija<\/span> <\/span>favorizuju<\/span> <\/span>karotidnu<\/span> <\/span>endarterektomiju<\/span> <\/span>kao<\/span> <\/span>metodu<\/span> <\/span>izbora<\/span> <\/span>u<\/span> <\/span>le\u010denju<\/span> <\/span>karotidne<\/span> <\/span>bolesti.<\/span><\/p>\n

              Karotidna angioplastika kod asimptomatskih pacijenata<\/p>\n

              Trenutno se angioplastika karotidnih arterija savetuje samo kod asimptomatskih pacijenata u centrima sa velikim brojem procedura i dokumetovano malom stopom periproceduralnog mo\u017edanog udara i smrti ili u sklopu kontrolisanih klini\u010dkih studija.<\/h5>\n<\/div>\n

              \"\"<\/p>\n

              \n

              \"\"<\/p>\n

              Prizidni tromb nakon implantacije karotidnog stenta. Cerebralna protekcija ne \u0161titi od kasnije embolizacije.<\/em><\/p>\n

              Benefit angioplastike<\/strong> karotidnih arterija kod asimptomatskih pacijenata bi tek trebalo da se doka\u017ee.<\/p>\n

              Terapijski izbori u odnosu na vaskularne i lokalne anatomske karakteristike<\/p>\n

              Angioplastika karotidnih arterija je indikovana u slu\u010daju o\u0161te\u0107enja kontralateralnog laringealnog nerva, prethodne radikalne disekcije vrata, cervikalne iradijacije, nakon prethodne endarterektomjie (restenoza), kod visoko polo\u017eene karotidne bifurkacije ili intrakranijalne ekstenzije karotidne lezije. <\/strong><\/p>\n

              Angioplastika karotidnih arterija se ne preporu\u010duje u pacijenata sa ekstenzivnim aterosklerotskim promenama aorte i supraaortnih grana, kalcifikacijama i tortuozitetima<\/p>\n

              Ner\u0111aju\u0107i \u010delik od kojeg su napravljeni stentovi (stainless still) nije inertan, kao svaki drugi strani materijal on je trombogen. Trombogenost stentova je uzrok tromboze i reokluzije arterije. Da bi se smanjila trombogenost, stent se mo\u017ee impregnirati: heparin, fosforilholin itd. Da bi se redukovala hiperplazija neointime koristi se dvostruka antitrombocitna i rana statinska terapija.<\/p>\n

              Pobolj\u0161anje ishoda nakon angioplastike karotidnih arterija:<\/p>\n

                \n
              • Angioplastiku karotidnih arterija (CAS)<\/strong> bi trebalo sprovesti pod dvojnom antitrombocitnom terapijom sa apirinom i klopidogrelom.<\/li>\n
              • Primenu dvojne antitrombocitne<\/strong> i statinske terapije <\/strong>treba zapo\u010deti pre angioplastike i nastaviti 3 meseca nakon procedure.<\/li>\n
              • Treba sprovesti programe treninga prakti\u010dnih ve\u0161tina karotidne angioplastike.<\/li>\n
              • Ure\u0111aji za cerebralnu protekciju su neophodni.<\/li>\n
              • Postoje\u0107i tipovi cerebralne protekcije imaju svoje specifi\u010dne indikacije tokom karotidnih intervencija.<\/li>\n
              • O\u010dekujemo nove, usavr\u0161ene generacije stentova.<\/li>\n<\/ul>\n

                Stent graftovi<\/strong> se implantiraju endoluminalnim procedurama, a slu\u017ee za oblaga- nje aneurizme ili traumatske lezije (krvarenje) arterije. Spoljna strana stentovanog grafta treba da omogu\u0107i urastanje okolnog tkiva i dobro fiksiranje za zdravi deo krvnog suda. Unutra\u0161nja strana mora biti glatka i netrombogena da bi odr\u017eavala dugotrajnu prohodnost grafta. Naro\u010dita korist od ove metode mogla bi se o\u010dekivati u traumatologiji. Politraumatizirani pacijent sa krvare\u0107om arterijskom lezijom najjednostavnije i najbr\u017ee se mo\u017ee zbrinuti implantacijom graft-stenta. Hirur\u0161ko le\u010denje postaje nepotrebno, gubitak krvi i stvaranje hematoma odmah prestaje.<\/p>\n<\/div>\n


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

                ENDOVASKULARNA HIRURGIJA A few bad reasons for doing something neutralise all the good reasons for doing it.Bertrand Russel Perkutane endovaskularne tehnike su manje traumati\u010dne za pacijenta i primenjivije u pacijenata sa visokim rizikom. Endovaskularna hirurgija nije limitirana samo na karotidne arterije, ve\u0107 omogu\u0107ava revaskularizaciju supraaortalnih grana. Me\u0111utim, perkutana transluminalna balon angioplastika (Percutaneous Transluminal Angioplasty PTA) […]<\/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-4589","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n21. 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