{"id":4796,"date":"2023-02-17T18:55:33","date_gmt":"2023-02-17T18:55:33","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=4796"},"modified":"2023-02-22T20:50:41","modified_gmt":"2023-02-22T20:50:41","slug":"22-indikacije-za-rekonstrukciju-supraaortalnih-stabala","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=4796","title":{"rendered":"22. INDIKACIJE ZA REKONSTRUKCIJU SUPRAAORTALNIH STABALA"},"content":{"rendered":"

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

<\/p>\n

ENDOVASKULARNA HIRURGIJA<\/h1>\n

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

\n

Svakome je dato da proglasi kraj Bo\u017ejeg stvaranja. Za mene ono jo\u0161 uvek traje.
<\/i>Nikola Tesla<\/em><\/p>\n<\/div>\n

\n

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><\/p>\n

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>(Percutaneous Transluminal Angioplasty PTA)<\/strong> <\/span><\/strong>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><\/span><\/p>\n<\/div>\n

\"\"<\/p>\n

\n

Ateroskleroza je daleko naj\u010de\u0161\u0107i uzrok oboljenja supraaortalnih grana koja dovode do ishemije mozga. Distribucija i u\u010destalost okluzivne bolesti supraaortalnih grana:<\/em><\/p>\n

\n<\/div>\n

\"\"<\/p>\n

\n

\n

<\/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

\n

Hemodinamski zna\u010daj<\/strong> okluzivne bolest supraaortalnih grana podrazumeva da stenoza kompromituje protok do kriti\u010dnog stepena (ishemija mozga).<\/p>\n

Hemodinamski uslovi za pojavu simptoma cerebralne ishemije se sti\u010du u slu\u010daju multiplih ekstenzivih ateroskleroti\u010dnih lezija supraaortalnih arterija, pogotovo u kombinaciji sa sr\u010danim oboljenjima (aritmije, low cardiac output).<\/p>\n

Hemodinamski mehanizam je ovde od ve\u0107eg zna\u010daja nego u oblasti karotidne cirkulacije. Na primer, lezija brahiocefali\u010dnog trunkusa se odra\u017eava na dve od \u010detiri arterije koje snabdevaju cerebralnu cirkulaciju, kao i desnu ruku.<\/p>\n

Zato su takve lezije \u010desto simptomatske.<\/p>\n<\/div>\n

\"\"<\/p>\n

\n

Visokostepena ateroskleroti\u010dna stenoza brahiocefali\u010dnog trunkusa sa potpunom trombozom zajedni\u010dke karotidne arterije levo.<\/em><\/p>\n<\/div>\n

\"\"<\/p>\n

\n

Emboligeni potencijal<\/strong> raste sa degeneracijom plaka i pojavom komplikovanih ateroskleroti\u010dnih lezija kao \u0161to su intramuralna hemoragija, egzulceracija i prizidna tromboza. \u201cNestabilan\u201d plak je izvor distalnih atero-arterijskih embolizacija mozga.<\/p>\n

Ulceracija ateroskleroti\u010dnog plaka je \u010desta u brahiocefali\u010dnom trunkusu. Zato je simptomatologija \u010desto fokalna.<\/p>\n

Embolijski i hemodinamski mehanizam mo\u017edane ishemije se kombinuju. Me\u0111utim, ako dominira embolizacija znaci ishemije \u0107e biti fokalni.<\/p>\n

Ako su bitniji hemodinamski poreme\u0107aji simptomi su obi\u010dno globalnog tipa.<\/p>\n<\/div>\n

\n
\n

Okluzija subklavijalne arterije levo.<\/em><\/p>\n

Aneurizma brahiocefali\u010dkog trunkusa.<\/em><\/p>\n<\/div>\n

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

\n

Fokalna ishemija mozga<\/strong> razvija se kod blokade krvotoka u odre\u0111enoj arte- riji zbog (mikro)embolizacije. Te\u017eina neurolo\u0161kog deficita zavisi od lokalizacije i opsega arterijske okluzije. Simptomi zavise od mesta embolizacije:<\/p>\n

\"\"Karotidni sliv<\/strong> snabdeva hemisfere velikog mozga, me\u0111umozak, bazalne ganglije, o\u010di i lice, pa \u0107e se simptomi projektovati iz ovih centara.<\/p>\n

\n

Ulcerisani arterioskleroti\u0107ni plak na po\u010detku brahiocefali\u010dnog <\/em>stabla
(visok emboligeni potencijal).<\/em><\/p>\n

\n<\/div>\n

\"\"<\/p>\n

\n

Ulkus luka aorte, zadnji zid.<\/em><\/p>\n<\/div>\n

\"\"<\/p>\n

\n

Ulkus po\u010detnog, prevertebralnog dela subklabijalne arterije.<\/em><\/p>\n

\u00a0<\/em><\/p>\n<\/div>\n

\n

Vertebrobazilarni sliv<\/strong> ishranjuje mo\u017edano stablo, mali mozak, produ\u017eenu mo\u017edinu i okcipitalne lobuse, pa \u0107e klini\u010dki odraz biti vertebrobazilarna insufi- cijencija.<\/p>\n

Globalna cerebralna ishemija nastaje na bazi op\u0161te redukcije protoka zbog arterijskih stenoza (ili okluzija).<\/p>\n

Ekstenzivnost ishemi\u010dkih lezija mozga, tip i trajanje simptomatologije zavisi od: stepena i du\u017eine stenoze, kolateralnog sistema, sistemskog krvnog pritiska itd.<\/p>\n

Globalna cerebralna ishemija<\/strong> nastaje na bazi op\u0161te redukcije protoka zbog arterijskih stenoza (ili okluzija). Ekstenzivnost ishemi\u010dkih lezija mozga, tip i trajanje simptomatologije zavisi od: stepena i du\u017eine stenoze, kolateralnog sistema, sistemskog krvnog pritiska itd.<\/p>\n

Dijagnoza<\/strong> oboljenja supraaortalnih grana<\/p>\n

    \n
  • Angio-neurolo\u0161ki nalaz,<\/li>\n
  • Neinvazivno ispitivanje,<\/li>\n
  • Arteriografija.<\/li>\n<\/ul>\n<\/div>\n


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

    ENDOVASKULARNA HIRURGIJA Svakome je dato da proglasi kraj Bo\u017ejeg stvaranja. Za mene ono jo\u0161 uvek traje.Nikola Tesla 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) ima […]<\/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-4796","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n22. INDIKACIJE ZA REKONSTRUKCIJU SUPRAAORTALNIH STABALA - KAROTIDNA HIRURGIJA<\/title>\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=4796\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"22. INDIKACIJE ZA REKONSTRUKCIJU SUPRAAORTALNIH STABALA - KAROTIDNA HIRURGIJA\" \/>\n<meta property=\"og:description\" content=\"ENDOVASKULARNA HIRURGIJA Svakome je dato da proglasi kraj Bo\u017ejeg stvaranja. Za mene ono jo\u0161 uvek traje.Nikola Tesla 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. 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