BACKYPAPHA

XHPYPFHJA
Tom 2.indb 689 25.05.2006 10:34:14
Tom 2.indb 690 25.05.2006 10:34:14
691 XHPYPFHJA
AHEBPH3MA HA AOPTA H AOPTHA
HCEKUHJA
Basuunu qax1u
Anenpusua na aop1a
Aop1anna pucexuuja
Peqepenuu

BA3HHHH OAKTH
Aopfanuafa aueepusua fpea pa ce pujaruocfuuupa npep pynfypupane: peucu ce-
koja aueepusua uoe pa ce fpefupa xupypuku. Manufe aueepusuu, ofkpueuu cny-
ajuo unu co ckpuuuur nporpaua, fpea pa ce uouufopupaaf c popeka ue poujaf
puueusuu kora euequfof op xupypukuof saqaf ro uapuuuyea pusukof op uufep-
eeuuujafa.
Onufuof nekap necuo uoe pa upe oyeu pa pujaruocfuuupa aopfanua aueepusua
co nouou ua exo-fouorpaquja eo ceojafa npakfuka.
Aopfanuafa pucekuuja cekorau fpea pa ce uua eo npepeup eo cnyaj ua cunua rpap-
ua onka, koja cyrepupa AHM, uo es EKF uaop eo npunor ua AHM.
Rauueuf co pucekuuja ua aopfa eepuau fpea pa upe npeqneu eo onuuka ycfauoea.
AHEBPH3MA HA AOPTA
Anenpusua na apouenanna aop1a
Apfepuockneposafa e uajeaeu efuonouku qakfop
85% op nauueufufe ce uau. Aueepusua ua aopfa ce uaora kaj 10% op uaufe uap
75-ropuuua eospacf.
Rannaunua nyncupaka uaca e funueu uaop eo ropuuof unu eo cpepuuof apoueu.
Roeekefo aueepusuu cnyajuo ce ofkpueaaf.
Rauueufufe ce anaf ua onka koja uoe pa uanukyea ua peuanua konuka unu ua
uuujapuua onka. Eonkafa ecfonafu spau kou rpof. Hajecfo, onkafa e suak
peka aueepusuafa e eo ekcnausuja, ufo apa xupypuku fpefuau.
Kanuuquuupaua aueepusua uoe pa upe cnyaeu uaop ua uafueua peupreurpa-
quja ua apoueu unu ua ypuuapeu cucfeu.
ujaruosafa uoe pa ce nofeppu co exofouorpaqcku npernep (uanpaeeu eo onufa
auynaufa, useepeu op oyeu onufu nekap.
1
Tpefuau
Xunepfeusuja kaj ppyrufe kappuoeackynapuu pusuk-qakfopu, ycneuuo fpea pa
upe fpefupaua.
Aueepusua co pujauefap co uap 3 cu ce uouufopupa co exo npernep, ua cekou
12 ueceuu. Kora pujauefapof ua aueepusuafa ke pocfurue 5 cu, kaj uau unu
4.5 cu kaj euu, ce cnpoeepyeaaf exo koufponu ua cekou 6 ueceuu.
Xupypuku fpefuau e uupuuupau kora aueepusuafa ke pocfurue uap 5.5 cu.
(nnp
2
-B)
1 Hepoc1anno no Maxeponuja
2 uup- uueo ua pokas

Tom 2.indb 691 25.05.2006 10:34:14

692 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
Okony 1% op aueepusuufe, co pujauefap 4 cu, pynfypupaaf ropuuuo, popeka
ropuuuo pynfypupaaf 10% op aueepusuufe ua 6 cu. Cupfuocfa op pynfypu-
paua aueypusua e 90% .
Aueepusuufe kou ce npoferaaf eo fopokanuafa npasuuua eepuau fpea pa ce
onepupaaf.
Rocfapu paka ua nauueufu co pokaaua aueepusua fpea pa upaf koufponu-
pauu co exo fouorpaquja (ckpuuuur). (nnp-C)
Anenpusua na 1opaxanna aop1a
Boouaeuo acuunfouafcka. Eonkafa cyrepupa ekcnausuja.
Aopfanua peryprufauuja
Tpaxeanua unu pouxanua kounpecuja unu napanusa ua qpeuueu uepe.
Rouekorau nocfou uapekuafocf ua epafuufe eeuu kako nocnepuua op kounpecuja
op aueepusuafa.
Moe pa upe eupnuea kako cnyaeu uaop ua uafueua peupreurpaquja ua rpapeu
kou.
Tpefuauof e xupypuku unu kousepeafueeu.
AOPTARHA HCEKUHJA
Tunuua nokanusauuja e acueupeufua aopfa (fun u fun ) u pecueupeufua fopakan-
ua aopfa (fun ). Tun e pucekuuja orpauueua ua acueupeufua aopfa. ucekuuja op
ppyrufe funoeu uoe pa upe npouupeua u ua apoueuanua aopfa.
Tyuuka uufepua pynfypupa u kpefa uaeneryea uery cnoeeufe op fyuuka uepuja.
Aopfafa e ecfonafu punafupaua, ufo uoe pa upe eupnueo ua uafueua peupreu-
rpaquja ua rpapeu kou.
Mapqauoe cuuppou ecfonafu opu co pucekuuja unu co auynoaopfanua ekfasuja u
aopfanua peryprufauuja.
Huuupeuuafa ua aopfanuafa pucekuuja e okony 10/uunuou/ropuuuo.
Cuun1ouu
Heuapeeu noefok ua cunua rpapua onka, es EKF suauu sa AHM.
Rauueufufe ce eoouaeuo uau co xunepfeusuja.
Pokanusauujafa ua onkafa uoe pa ce ueuyea kako ufo uanpepyea pucekuujafa.
Eonkafa spau kou peruu, cnuuo kako npu AHM, eknyyeajku ru eunuuafa u uenuefo.
-ecfonafu onkafa ce yecfeyea ua rpof
Ocfauafafa cuunfouafonoruja saeucu op oknypupanefo co pucekuuja ua aopfanuufe
rpauku, np: ucxeuuja ua uosok, cpue, ypesu u upeea.
Moua e u akyfua aopfanua peryprufauuja (uoe uyu)
Haopu
Acuuefpuuocf ua nync (kaj uan poj nauueufu) Cpuee uyu, sapapu aopfanua pe-
ryprufauuja
Xunepfeusuja, noceuo uspaseua kaj pucfanuu pucekuuu
EKF uaopof ue nokayea AHM, uo uoe pa nokae neea eeufpukynapua xunepfpo-
quja, cfap HM unu ucxeuuja ako pucekuujafa ru saqafuna kopouapuufe kpeuu ca-
poeu
Hafueua peupreurpaquja ua rpapeu kou uoe pa nokae punafupau nak ua aopfa,

Tom 2.indb 692 25.05.2006 10:34:15

693 XHPYPFHJA
uo uajecfo e co uopuaneu uaop
Tpaucesoqareanuo exo e opnuua npuuapua npouepypa. Kounjyfepusupaua fouor-
paquja, Maruefua pesouauua unu auruorpaquja ce nofpeuu sa quuanua pujaruosa.
Tpe1uan
Cucfonuuof npufucok fpea pa ce cuuu ua uopuanuu 100-120 uuXr.
Rpeuof ekop eknyyea 10 uun uuqepunuu (useakau), uufpafua (unu uufponpycuf)
uuqysuja, efanokep u eqekfua auanresuja.
ucekuuja ua acueupeufua aopfa ufuo fpea pa ce onepupa.
Ees xupypuku saqaf nporuosafa e uuory noua.
Rpuuapuuof fpefuau ua pucekuuja ua pecueupeufua aopfa e kousepeafueeu; cuuy-
eane ua kpeuuof npufucok u nyncof...
Tpouonusafa e koufpauupuuupaua
PEOEPEHUH
Lederle FA, Simel DL. Does this patient have abdominal aortic aneurysm? JAMA
1999;281:77-82
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-998387. n: The Cochrane Library, ssue 1, 2001. Oxford: Update Software
The UK Small Aneurysm Trial Participants. Mortality results for randomized trial of early
elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms.
Lancet 1998;352:1649-55
Salo JA, Soisalon-Soininen S, Bondestam S, Mattila PS. Familial occurrence of
abdominal aortic aneurysms. Ann ntern Med 1999;130:637-42
Bertram DA. Endovascularly placed grafts for infrarenal abdominal aortic aneurysms:
a systematic review of published studies of effectiveness. Technology Assessment
programme 8 (VA Medical Center. Boston). 9. 1999. 1-22
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-998450. n: The Cochrane Library, ssue 1, 2001. Oxford: Update Software
Endoleak after stent-graft treatment of abdominal aortic aneurysm: a meta-analysis of
clinical studies. British Journal of Surgery 1999;86:581-587
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-991370. n: The Cochrane Library, ssue 2, 2001. Oxford: Update Software
Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl
J Med 2003;348(19):1895-901
EBM GuideIines 26.02.2004 www.ebm-guideIines.com
Yna1c1no1o 1pea pa ce axypupa epnam na 4 ropunu
Rpepnupeno cnepno axypupane po qenpyapu 2008 ropuna

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Tom 2.indb 693 25.05.2006 10:34:15
694 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
HCXEMH-HA EOPECT HA OPHHTE
EKCTPEMHTETH
Uenu
Cuu1ouu u snauu na xponuuna ucxeuuja
Axy1na sarposynauxa ucxeuuja na exc1peuu1e1o1
Kpu1uuna ucxeuuja na exc1peuu1e1o1
Ronpsanu poxasu
Peqepenuu

UERH
a ce npenosuae akyfuafa ucxeuuja, koja ro sarposyea ekcfpeuufefof u pa ce ynafu
eo onuuka ycfauoea
a ce pujaruocfuuupa xpouuua u kpufuua ucxeuuja ua ekcfpeuufefof. a ce opra-
uusupaaf uafauouuu pujaruocfuku npouepypu es opnarane.
a ce nofeppu cycnekfua nepuqepua apfepucka oknysueua onecf (RAOE), co no-
uou ua ponnep-couorpaquja
a ce fpefupa ucfoepeueuo nocfojuafa kopouapua cpueea onecf u pa ce npeeeuupa
nofeuuujaneu uosoeu ypap. Rauueufufe co RAOE, eoouaeuo cfpapaaf op reue-
panusupaua afepockneposa. Hueuafa nporuosa ue e pefepuuuupaua op ucxeuujafa
ua ekcfpeuufefof. 4apuakofepanujafa uoe pa upe op kopucf sa uauanyeane ua
uueofo ua nunupu. (nnp-C)
XPOHHHHA HCXEMHJA
Cuun1ouu u snauu
Knaypukauuo uufepuufeuc ce pequuupa kako onka eo ekcfpeuufefof npu sauop,
koja ucesuyea no opuop op uekonky uuuyfu. Rauueufof e eo uouocf noefopuo pa
ja nouuue ucfafa pucfauua.
Cfypeuu uose.
Eonka eo uup (uaeeep), koja nouuuyea npu paspeuyeane unu npu cnyufane uapo-
ny ua ekcfpeuufeof (np: uosefe eucaf npeky ueuua op kpeeef)
Fyene ua nepuqepua enakuefocf.
Cuuppouof Leriche: nocnepuua op oknysuja ua pucfanua aopfa, npepuseukyea cna-
ocf ua peafa ponuu ekcfpeuufefa, knaypukauucku feukofuu eo ropuuof pen op ua-
fkoneuuuafa u uunofeuuuja
Oknysuja ua unukanua apfepuja npepuseukyea knaypukauuja eo uafkoneuuua u nof-
koneuuua. 4euopanua oknysuja npfepuseukyea kanypukauuja eo nofkoneuuua, a no-
nufeanua oknysuja eo cfananofo.
Rannauuja ua nync ua apfepuufe ua cfananofo:
Rannauuja ua a. dorsaIis pedis i a. retromaIeoIaris.
Rpucycfeo ua ofok ua uorafa uoe pa ro ofeue npernepof.

Tom 2.indb 694 25.05.2006 10:34:15

695 XHPYPFHJA
Kanunapuuof nync ua nekapof (npernepyea) uoe pa ja kounukyea nannauujafa.
Haop ua nyncauuu ua peefe apfepuu ucknyyea nocfoene curuuqukaufua oknysueua
onecf.
Rofeppa ua uaopof co ponnep
4euopan pyuf (nnp-C)
Heunnasunen 1pe1uan na xponuuna ucxeuuja
3apaua sa nyuene
Hajeaua uepka
Ropopyeane ua cocfojafa ce jaeyea kaj 85% op nauueufufe, a nporpecujafa
ua onecfa ce ycnopyea.
4usuka akfueuocf (nnp-A)
Ha nauueufof uy ce npenopayea pa neuau uajuanky epeu ac pueeuo.
Kora ke ce jaeu onkafa, nauueufof fpea pa ce opuopu uekonky uuuyfu u nofoa
pa npoponu co neuaenefo.
Ropopyeane ua cocfojafa uoe pa ce oekyea no fpu ueceuu.
3uaajuo nopopyeane ue ce oekyea kaj nauueufu co knaypukauucku uufepean
nop 50 uefpu u kaj nauueufu co oknysueua onecf ua unuaka.
4apuako-fepanuja
Acnupuu 100-250 ur pueeuo. Eqekfof op acnupuuof ue e pokaau eo npeeeuuuja
ua nporpecujafa ua nepuqepuafa apfepucka onecf. Ho pokaau e eqekfof ua
acnupuuof kaj kopouapuafa onecf u no saqafu sapapu nepuqepua peeackyna-
pusauuja. (nnp-A)
Pekoeu kou ro uauanyeaaf uueofo ua nunupu eo kpefa (nnp-C). ue uuaaf
eqekf kaj cpueea kopouapua onecf u ja ycnopyeaaf nporpecujafa ua RAOE.
Clopidogrel u dipyrimadole uoaf pa ce papaf kako saueua sa acnupuuof eo cny-
aj ua anepruja unu npu pesucfeuuuja kou acnupuuof.
Reufokcuqunuuof eo posa op 400 ur fpunafu ua peu uoe pa pape eqekf no
uekonky uepenu.(nnp-C)
Cenekfueuufe efa-nokafopu uoe pa ce es eqekf, co ucknyok ua cnyau
co kpufuua ucxeuuja. Hupuuupauu ce eo cnyaj co koersucfupaka kopouapua
onecf u/unu xunepfeusuja
Pokanua fepanuja
Roceuo eaua kaj nauueufu co pujaefec uenufyc
Roepepu, fonna unu napua eopa fpea pa ce useruyea
Hnnasunen 1pe1uan na xponuuna ucxeuuja
Knaypukauuo uufepuufeuc uepefko npefcfaeyea cepuoseu pusuk qakfop. Pusukof
e noroneu npu koersucfupaka kopouapua unu uepepo-eackynapua onecf. Toa ro
pefepuuuupa npeueyeanefo.
Huuuujanuuof fpefuauof ua RAOE e kousepeafueeu npecfauok co nyuene u nocfoja-
uo peuene (stop smoking keep walking). (nnp-A)
Auruonnacfuka e epuocfaeeu u eoouaeuo eqekfueeu fpefuau. (nnp-B). Backynapeu
xupypr (nnp-C) fpea pa upe koucynfupau eo cnyaj ua enouyeane ua cocfoja-
fa. ypu u uuuuuanua cuunfouafcka npokcuuanua oknysuja uoe pa upe suaaeu
uaop, koj uoe pa ce fpefupa co (nnp-C), anou punafauuja unu nnacupane cfeuf.
Rpokcuuanuufe oknysuu ce uajecf uaop kaj nyuau, popeka pucfanuufe kaj pujae-
fuapu.

Tom 2.indb 695 25.05.2006 10:34:15

696 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
Aopfo-uqeuopaneu aj-nac co Y-npofesa e equkaceu fpefuau co uap 80% npeu-
eyeane uap nef ropuuu ua npoopuocfa ua rpaqfof. (nnp-C)
Kaj qeuopo-nonnufeanuof aj-nac, 5-ropuuuofo sayeyeane ua npoopuocfa e okony
50%. Oeoj npoueuf e ueufo nouan kaj qeuopo-fuujanuuof aj-nac.
ucfanuufe pekoucfpykuuu ce kounnuuupauu saqafu co uusok npoueuf ua npeu-
eyeane.
AKYTHA 3AFPO3YBAHKA HCXEMHJA HA EKCTPEMHTETOT
Cocfojafa uoe pa upe npepuseukaua op ersauepauuja ua xpouuua ucxeuuja
kora afepocknepofcku npoueuef kpeeu cap cfauyea fpouofueu, oknysuja no npep-
xopua eackynapua pekoucfpykuuja unu euonuja, uajecfo, op kappuoreuo nofekno.
Cuun1ouu u snauu
Eonka, nepuno ua ekcfpeuufefof, ofcycfeo ua nync, ryene ceusuunufef u uofo-
puka.
Pasnuka eo feunepafypafa ua onuuof u sppaeuof ekcfpeuufef. Fpauuua uery fonno
u napuo ua saoneuuof ekcfpeuufef uoe pa upe eeupeufua.
ujarnosa
Euonujafa uua akyfeu noefok. Rpuuapuafa npuuua e uajecfo afpujanua qupu-
nauuja unu uuqapkf ua uuokappof.
Roefokof e saaeeu eo cnyau ua nporpepupaka xpouuua ucxeuuja. Rocfou
auauuecfuku nopafok sa knaypukauucku feukofuu u/unu uaop ua RAOE ua ppyrafa
uora.
uqepeuuujanuo pujaruocfuku fepa pa upe ucknyeua uacueua pnaoka unuo-
qeuopanua eeucka fpouosa (ofok, uujauosa, eeucka kourecfuja)
Hcxeuuua oknysuja, koja paea ryene ua uofopukafa, ecfonafu uoe pa cuuynupa
uosoeu ypap.
KPHTHHHA HCXEMHJA HA EKCTPEMHTETOT
Kpufuuafa ucxeuuja e pequuupaua kako eoeep eo raurpeua
ucfanua ynuepauuja, koja ue sasppaeyea eo pok op pee uepenu, e eucoko cycnekfua
sa kpufuua ucxeuuja ua ekcfpeuufefof. ucfanua raurpeua (uuqapkf ua naneu) e
funuuo sa ucxeuuja, ucfo kako u ynuepauuu ua cfananofo, uapeop op pekyufan-
uufe souu.
Rauueufof ekcfpeuufefof ro yecfeyea kako napeu, ucfoepeueuo nocfou nepuno
u/unu uujauosa.
-ecfonafu e acouupaua co pujaefuua uukpoauruonafuja.
Rauueufof uoe pa ja yecfeyea ucxeuujafa kako sppeeuocf.
Beucka uucyquuueuuuja u eeucku ynkycu uoaf pa ja ycnouaf pujaruocfukafa.
Hcxeuujafa fpea pa ce cuefa sa kpufuua ako:
Eonka eo uup, eoouaeuo uaeeep.
Ynuepauuja ua cfanano unu raurpeua, koja ue sasppaeyea, ankle-brachial uupekc
(AEH) < 0.85.
onnep-couorpaqcku uoe pa upe co nauo uopuaneu uaop kaj nauueufu co
pujaefec. Cnau u uouofouu ejekuuouu seyuu ja ofkpueaaf ucxeuujafa.

Tom 2.indb 696 25.05.2006 10:34:15

697 XHPYPFHJA
Bacxynapna xupypruja npu axy1na u xpu1uuna ucxeuuja
Akyfuafa ucxeuuja apa ufua u ueopnoua-xocnufanusauuja.
Euonekfouuja e epuocfaeua onepauuja useopnuea eo nokanua auecfesuja pypu u
kaj noeospacuu nauueufu u onufa noua cocfoja. uqepeuuujanuo pujaruocfuku
fpea pa ce seue eo osup peka u fpouosafa ua afepocknepofcku usueuef apfe-
pucku kpeeu cap uoe pa upe npuuua sa akyfua ucxeuuja.
Akyfuo uacfauafafa fpouosa ua xpouueu fepeu uoe pa upe peueua co uufpa-
apfepucka uuqysuja co fpouonufueu areuc.
Xpouuuafa ucxeuuja uuory ecfo apa eupoeackynapuu npouepypu unu nepuqepua
aj-nac xupypruja.
Kousepeafueeu fpefuau e eosuoeu ako nauueufof uua oyeaua uofopuka u ceu-
suunufef, kako u rnypeu apfepucku npufucok noroneu op 30 uuXr. Uujauosafa u
uyckynuafa onka fpea pa upaf ucknyeuu.
Kpufuuafa ucxeuuja e ecfonafu npuppyeua co cfeuosu ua ponr cerueuf ua uanu
kpeuu capoeu. Rauueufufe ce ecfonafu noeospacuu, co koersucfupaku saonyeana
u kpafko epeue ua oekyeauo npeueyeane. Aunyfauujafa fpea pa upe useruafa
kaj nauueufu kou uoaf pa ce peuaf.
Rpuuapua aunyfauuja e anfepuafuea kaj nauueufu eo noua onufa cocfoja, kou ue
uoaf cauocfojuo pa ce peuaf. Aunyfauujafa e saponufenua kora nonoeuua op
cfananofo e raurpeuosuo.
Ro aunyfauujafa, sapapu ucxeuuja, nauueufufe cu oyyeaaf pa ce peuaf co npo-
fesa.
ROBP3AHH OKA3H
Auruonnacfukafa paea nocna pesynfaf op aj-nac co eeucku rpaqf, uo eo oppepeuu
cocfoju paea ekeueaneufeu pesynfaf, cnopepeu co aj-nac co nonufefpaqnyopefu-
neu. ( nnp-C)
Hnonpocf uoe pa upe eqekfueeu kako cnacyeaku fpefuau. (nnp-B)
Konop ponnepof (pynnekc ckeu) e npeuusua ueuueasueua uefopa eo pujaruocfuuu-
panefo u cnepene ua apfepuckafa oknysueua onecf ua ponuufe ekcfpeuufefu, kaj
nauueufu co knaypukauuo unu kpufuua ucxeuuja. (nnp-B)
equpofupe uua useecua npepuocf npep nnaueo, eo sroneuyeane ua knaypuka-
uuckuof uufepean. (nnp-A)
He nocfojaf poeonuo pokasu sa onpaepauocfa ua fpefuauof co eufauuu E kaj nauu-
eufu co knaypukauuo uufepuufeuc. (nnp-D)
Aufukoarynaucu (xenapuu u opanuu aufukoarynaucu) ue ce op kopucf kaj nauueufu co
knaypukauuo uufepuufeuc. (nnp-B)
Bufauuu K aufarouucfufe ro nopopyeaaf npeueyeanefo ua eeuckuof rpaqf, uo ue
u ua cuufefckuof. Aufuarperauuckafa fepanuja uoe pa ro nopopu npeueyeanefo
ua cuufefckuof rpaqf, uo ue u ua eeuckuof. (nnp-C)
Reufokcuqunuuof puckpefuo ro nopopyea qyukuuouanuuof cfafyc kaj nauueuf co
cpepuo uspaseuu knaypukauuu. ( nnp-C)
Hufpaeackynapua paxufepanuja uoe pa pape eqekf eo nopopyeane ua npofokof
ua qeuopo-nonnufeanuufe apfepuu kaj RAOE. ( nnp-C)
Fuukro unoa uua nuuufupau eqekf kaj nauueuf co knaypukauuu. ( nnp-B)
Heua poeonuo pokasu sa eqekfof ua nokanuufe npeepcku u areucu eo fpefuauof ua
apfepuckufe ynuepauuu. (nnp-D)

Tom 2.indb 697 25.05.2006 10:34:16

698 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
Cfuuynauujafa ua pefuuof uosok paea nopoap eqekf op cfaupappuuof kousepea-
fueeu fpefuau kaj nauueufu co xpouuua uxeuuja ua ekcfpeuufefof kaj kou e ueeos-
uouo pa ce useepe pekoucfpykfueua eackynapua npouepypa. (nnp-B)
Tpefuauof co Ouera-3, uacuufe kucenuuu, paea uoxeuucku u xeuopuuaucku eqekf,
uo ueua poeonuo pokasu peka ro nopopyeaaf knuuukuof kpaeu pesyfaf. ( nnp-C)
PEOEPEHUH
Leng GC, Price JF, Jepson RG. Lipid-lowering pharmacotherapy for lower limb ischaemia.
The Cochrane Database of Systematic Reviews, Cochrane Library number: CD000123.
n: The Cochrane Library, ssue 2, 2002. Oxford: Update Software. Updated frequently.
McGee SR, Boyko EJ. Physical examination of chronic lower-extremity ischemia: a
critical review. Archives of nternal Medicine 1998;158:1397-1364
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-999281. n: The Cochrane Library, ssue 2, 2001. Oxford: Update Software
Girolami B, Bernardi E, Prins MH, Ten Cate JW, Hettiarachchi R, Prandoni P, Girolami
A, Buller HR. Threatment of intermittent claudication with physical training, smoking
cessation, pentoxifylline and nafronyl. Archives of nternal Medicine 1999;159:337-345
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-998439. n: The Cochrane Library, ssue 4, 2000. Oxford: Update Software
Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. The Cochrane
Database of Systematic Reviews, Cochrane Library number: CD000990. n: The
Cochrane Library, ssue 2, 2002. Oxford: Update Software. Updated frequently.
Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of
claudication pain: a meta-analysis. JAMA 1995;274:975-980
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-952716. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Tangelder MJ, Lawson JA, Algra A, Eikelboom BC. Systematic review of randomized
controlled trials of aspirin and oral anticoagulants in the prevention of graft occlusion
and ischemic events after infrainguinal bypass surgery. Journal of Vascular Surgery
1999;30:701-6709
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-992060. n: The Cochrane Library, ssue 2, 2001. Oxford: Update Software
Collaborative overview of randomised trials of antiplatelet therapy: Maintenance of
vascular graft or arterial patency by antiplatelet therapy. BMJ 1994;308:159-168
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-948031. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Ernst E. Pentoxifyllin for intermittent claudication: a critical review. Angiology
1994;45:339-345
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-940251. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Leng GC, Davis M, Baker D. Bypass surgery for chronic lower limb ischaemia. The
Cochrane Database of Systematic Reviews, Cochrane Library number: CD002000. n:
The Cochrane Library, ssue 2, 2002. Oxford: Update Software. Updated frequently
Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous transluminal
angioplasty and stent placement for aortoiliac occlusive disease. Radiology 1997;204:87-
96
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-970844. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software

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2.
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4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Tom 2.indb 698 25.05.2006 10:34:16
699 XHPYPFHJA
de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac occlusive
disease: a meta-analysis. J Vasc Surg 1997;26:1-12
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-978276. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Hunink M, Wong JB, Donaldson MC, Meyerovitz MF, Harrington DP. Patency results
of percutaneous and surgical revascularisation for femoropopliteal arterial disease.
Medical Decision Making 1994;14:71-81
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-978274. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Loosemore TM, Chalmers TC, Dormandy JA. A meta-analysis of randomised placebo-
control trials in Fontaine stage- and stage-V peripheral occlusive arterial disease.
nternational Angiology 1994;13:133-142
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-940341. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Koelemay MJ, Denhartog D, Prins MH, Kromhout JG, Legemate DA, Jacobs MJ.
Diagnosis of arterial disease of the lower extremities with duplex ultrasonography. Br J
Surg 1996;83:404-409
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-960604. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Ferrari P, Clerici G, Gussoni G, Nazzari M. Defbrotide versus placebo in the treatment
of intermittent claudication. Drug nvestigation 1994;7:157-160
The Database of Abstracts of Reviews of Effectiveness (University of York), Database
no.: DARE-940223. n: The Cochrane Library, ssue 4, 1999. Oxford: Update Software
Klejnen J, Mackerras D. Vitamin E for intermittent claudication. The Cochrane Database
of Systematic Reviews, Cochrane Library number: CD000987. n: The Cochrane Library,
ssue 2, 2002. Oxford: Update Software. Updated frequently.
Cosmi B, Conti E, Coccheri S. Anticoagulants (heparin, low molecular weight heparin
and oral anticoagulants) for intermittent claudication. The Cochrane Database of
Systematic Reviews, Cochrane Library number: CD001999. n: The Cochrane Library,
ssue 2, 2002. Oxford: Update Software. Updated frequently
Moher D, Pham B, Ausejo M, Saenz A, Hood S, Barber GG. Pharmacological
management of intermittent claudication: a meta-analysis of randomised trials. Drugs
2000:59;1057-70.
The Database of Abstracts of Reviews of Effectiveness (University of York), Database no.:
DARE-20001266. n: The Cochrane Library, ssue 1, 2002. Oxford: Update Software
EBM GuideIines 21.08.2004 www.ebm-guideIines.com
Yna1c1no1o 1pea pa ce axypupa epnam na 4 ropunu
Rpepnupeno cnepno axypupane po anryc1 2008 ropuna
18.
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Tom 2.indb 699 25.05.2006 10:34:16
700 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
RPOLHPEHH BEHH H
BEHCKA HHCY4HUHEHUHJA
HA OPHHOT EKCTPEMHTET
Onm1o
Ra1oqusuonoruja na nencxa1a uupxynauuja na ponnu1e exc1peuu1e1u
3nauu u cuun1ouu
ujarnosa
Rpunuunu na 1pe1uan
Peqepenuu

ORLTO
Rpouupeuufe eeuu ce uuory ecfo saonyeane (npeeaneuua po 50% op eospacua
nonynauuja)
Rpouupeuufe eeuu ecfonafu ce enouyeaaf sa epeue ua peueuocf.
Cuunfouufe nokayeaaf roneua eapujauuja u ue cekorau kopenupaaf co pojof ua
noepuuu eapukcu. 3apapu oea, ofcfpauyeanefo ua eapukosufefufe uecekorau eopu
kou fpajuo onopaeyeane.
Xupypukuof npucfan fpea pa upe uupuuupau ako eeuckafa uucyquuueuuuja e
epsaua co kounnukauuu. Xupypukuof fpefuau, sapapu kosuefuku npuuuu, ue e
npepuef ua oea ynafcfeo.
Rpu npeuof npernep e eauo pe ce ucknyu nocfoene ua cocfoju kou paeaaf cuu-
nfouafonoruja ua ponuufe ekcfpeuufefu (uuujanruja, apfpanruja, Eekepoea uucfa,
kounapfueuf cuuppou)
Xupyprujafa sa npouupeuu eeuu cfauyea c nocenekfueua co pen pa ce coyeaaf
ufo e uouo noeeke eeuu. 3ppaeu eeuu uoe pa upaf uckopucfeuu eo upuuua kako
rpaqfoeu.
RATOOH3HOROFHJA HA BEHCKATA UHPKYRAUHJA HA ORHH-
TE EKCTPEMHTETH
o 90% op eeuckuof npofok ce ocfeapyea npeky pnaokuof eeucku cucfeu.
Roepuuufe eeuu ce opuecyeaaf kako kpeuu aseuu op kape kpefa ce uacoyea kou
pnaokufe eeuu npeky nepqopaufuufe eeuu.
Myckynuafa nyuna ua ponuuof ekcfpeuufef oeosuoyea eqekfueua uupkynauuja, a
eaneynufe ua pnaokufe eeuu ro cnpeyeaaf peqnykcof.
Roepepeuuof eeucku sup npepuseukyea peqnykc ua kpefa, koj uoe pa eopu kou
eeucka xunepfeusuja. Kako ufo eeuckafa xunepfeusuja ce enouyea, qyukuujafa ua
nepqopaufuufe eeuu uoe pa upe aqekfupaua, ufo eopu kou cekyupapua pnaoka
eeucka uucyquuueuuuja.
Rponourupaua eeucka xunepfeusuja uuuuujanuo npepuseukyea nojaea ua ofok ua uo-
rafa. Rofoa cnepu nojaea ua xonepnurueufauuja, ckneposa ua cykyfauofo fkueo u

Tom 2.indb 700 25.05.2006 10:34:16

701 XHPYPFHJA
nojaea ua ynuepauuu.
Ropaueuuafa feopuja sa uukounefeufuocfa ua nepqopaufuufe eeuu, kako npuuua
sa nojaeafa ua ofok u npoueuufe ua koafa u nofkojefo peuec e poeepeua eo npa-
uane. onnep-couorpaqckufe cfypuu nokayeaaf qusuonouku peqnykc ua nepqo-
paufuufe eeuu kaj acuunfouafcku nauueufu. Op ppyra cfpaua, eo cnyaj ua feuka
uucyquuueuuuja ua noepuuufe eeuu nocfou npofok uapony, kako nocnepuua ua uu-
kounefeufuu npokcuuanuu eaneynu ua eeua caqeua uarua. Kpefa ce uacoyea kou
pnaokufe eeuu npeky nepqopaufuufe eeuu.
Bucfuucka cuunfouafcka uukounefeufuocf ua nepqopaufuufe eeuu uoe pa upe
acouupaua co peqnykc op pnaokufe eeuu unu co nponourupaua ekcecueua eeucka
uupkynauuja pon ponuuof ekcfpeuufef npepuseukaua op uukounefeufuocf ua noe-
puuuof eeucku cucfeu.
Rocfqneufuuuof cuuppou, uacfauaf no pnaoka eeucka fpouosa, ce uapekyea
- cekyupapuu eapukosuu eeuu.
3HAUH H CHMRTOMH
Pokanusupaua onka, yecfeo ua cferane unu neene, koe ce enouyea eo fekof ua
peuof, ocoeuo npu ponrofpajuo cfoene unu cepene.
Rouekorau, nojaea ua onka okony eapukosufefufe npu qusuka akfueuocf.
3auop u ofok ua ekcfpeuufefof eo eeepuufe acoeu.
Hokuu rpeeu, onka eo ekcfpeuufefof unu nocfojau sauop.
Bo cfoeka nonoa, eupnueu uaapeuu, fopfyosuu eeuu eo npepen ua nop u/unu
uapkoneuuuafa.
Koafa eo ponuufe napfuu ua uorafa, noceuo ua uepujanuafa cfpaua, uoe pa cfa-
ue ucfeueua rpya, nurueufupaua nopapu xpouuuo sroneueuuof eeucku npufucok.
Moua e u nojaea ua ynuepauuu.
Disability score
Cxop (pesyn1a1) 1exuna na cuun1ouu1e
0 acunfouafcku
1 Cuufouafcku, uo co oyeaua qyukuuja es ynfpea ua kounpecueuu
opanu unu noppeu aupa
2 cuunfouafcku ueuouocf ocyu acoeuofo paofuo epeue pa ce nouuue
es kounpecueuu opanu unu noppeu aupa
3 ueuouocf ocyu acoeuofo paofuo epeue pa ce nouuue H nokpaj
uocenefo kounpecueuu opanu unu noppeu aupa
HJAFHO3A
Uenfa e pa ce onuue funof u ekcfeusueuocfa ua uupkynafopuafa onecf, pa ce kope-
nupa uaopof co cuunfouufe ua nauueufof, kako npepycnoe sa uunneueufupane ua
fouuof fpefuau (UEAR knacuqujakuuja)
Knuuukuof npernep fpea pa noue co uucnekuuja ua koafa: ekcfeusueuocf u no-
kanusauuja ua eapukosufefufe, ofok ua uorafa, uupypauuja, cfacuc pepuafufuc, nur-
ueufauuja, nunopepuafockneposa, ynuepauuu.
Apfepucka uupkynauuja: feunepafypa ua ekcfpeuufefof, nepuqepuu nyncauuu.
Okony 90% op npouupeuufe eeuu uoe pa upaf upeufuquuupauu u nokanusupauu
co paeu ponnep (handheId penciI DoppIer). Oykafa sa paofa co oeoj anapaf e

Tom 2.indb 701 25.05.2006 10:34:17

702 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
epuocfaeua u e opnuuo cpepcfeo sa epuene ckpuuuur npernepu).
Konop ponnep, pynnekc ckeu, e uefop ua npe usop eo pujaruocfuka ua nopeuefy-
eanafa ua pnaokuof eeucku cucfeu u auafouckuof kypc u kounefefuocf ua eeua
caqeua napea.
Peupreuonoukufe koufpacfuu uefopu, eapukorpaquja ce cynneueufapuu uefopu,
kou uajecfo ce kopucfaf npeponepfueuo sa uanuur ua eeuckafa auafouuja.
UEAR xnacuquxauuja
U - (cIinicaI) knuuuku (a= acuunfouafcku, c= cuunfouafcku)
E - (etioIogy) efuonoruja (koureuufanuu, npuuapuu, cekyupapuu)
A - (anatomic ndings) auafoucku uaop
R - (pathophysioIogicaI component) nafoqusuonouku kounoueufu (Rp=peqnykc,
Ro = oncfpykuuja)
RPHHUHRH HA TPETMAH
Uenfa e onecuyeane ua cuunfouufe u npeeeuuuja ua kounnukauuufe (kpeapene op
eapukc, nepuqepua unu pnaoka eeucka fpouosa, ynuepauuu)
a ce ucfakue nofpeafa u eauocfa ua pepoeuafa qusuka akfueuocf u koufpona
ua feuuafa, koko npeeeuuuja ua nporpecujafa ua eeuckafa uucyquuueuuuja.
Konsepna1unen 1pe1uan
Kounpecueuu opanu
Rpe fpefuau ua usop kaj nauueufu co necuo uspaseua cuunfouafonoruja, sa epeue ua
peueuocf u ecfonafu fpajuo no xupypuka uufepeeuuuja (Taena 1)
Taena 1
Knaca na xounpecuja xounpecuja, uuXr Hnpuxauuja
kounpecueuu opanu <15 neceu ofok
npoqunakca

knaca 1 15 - 20 necuo uspaseuu npouupeuu eeuu

knaca 2 20 - 30 jacuo eupnueu npouupeuu eeuu
no eackynapeu saqaf

knaca 3 30 - 40 cunuo uspaseuu npouupeuu eeuu

nponeuu co pnaok eeucku cucfeu

Xupypmxu 1pe1uan
Op epeua cfpaua, sapapu uoeufe uuqopuauuu eo epcka co oeaa cocfoja, oese-
peuu op nocnepuufe cfypuu, a c yufe uepoeonuufe pecypcu op ppyra cfpaua, ro
poeepyeaaf xupypukuof fpefuau po ekcfeusueua peeusuja.
Xupypukuof fpefuau ua noepuuufe eeuu e uupuuupau kora apekeafuufe kounpecue-
uu opanu ue poeepyeaaf po onecuyeane ua cocfojafa, a cuunfouafonorujafa ro
kounpouufupa uopuanuofo ueeene ua nauueufof. Xupypukuof fpefuau, ucfo faka,
e uupuuupau kora suauufe u cuunfouufe ua onecfa ykayeaaf ua paseueane ua
yufe nocepuosua eeucka uucyquuueuuuja.
Knacuuuof cfpunuur ua eeua caqeua uarua u napea, ecfonafu poeepyea po ou-
fefyeane ua nepueackynapuofo ueko fkueo u eo noeekefo cnyau e uenofpeuo ek-

Tom 2.indb 702 25.05.2006 10:34:17

703 XHPYPFHJA
cfeusueua npouepypa. Cerauuuof cfae e peka oufefeuuof pen ua rnaeuofo cfeno
e nokanusupuo eo npenouckuof pen u sapapu foa e uenofpeeu cfpunuurof ua puc-
fanuufe napfuu.
3a epeue ua saqafof saphenous junction u uejsuuufe rpauku ce nerupaaf.
Bapukosufefufe ce ofcfpauyeaaf npeky uanu kouu uuuusuu, no ufo cnepu cfpunuur
co nouou ua cneuujanuo usrofeeu uefaneu cef (pefporpapua nuu cfpunuur uefopa).
Cfaeoeufe eo epcka co xupyprujafa ua nepqopafopuufe eeuu, ucfo faka, ce usueue-
fu. Cfypuufe nokaaa peka uauanyeanefo ua eeuckuof npufucok, npepuseukau op
noepuua eeucka uucyquuueuuuja, uoe pa ja noepafu kounefeufuocfa ua nepqo-
pafopufe.
Cockett u Puufou ja eoeepyeaaf ucfopuckafa fexuuka ua nerupane ua uukounefeuf-
uufe nepqopafopu. Oeaa npouepypa eue onfepefeua co pojuu cepuosuu kounnu-
kauuu u peuec e saueuefa co CERC (cyqacuuan eupocuonuu nepqopafop cypreps,
cyqacuujanua eupockoncka nepqopafop xupypruja). Bauocfa ua oeaa npouepypa
ocfauyea koufpoeepsua, uako uekonky cfypuu nokaaa uecnopeu u ps eqekf eps
sasppaeyeanefo ua kouufe eeucku ynuepauuu.
Peqnykcof, npepuseukau op uukounefeufuocfa ua eaneynufe ua pnaokufe eeuu,
uoe pa upe uauaneu co eaneynapeu xupypuku saqaf. Beuckufe eaneynu uoe pa
upaf pekoucfpyupauu no euafpeueu unu no uapeopeueu uefop.
Rocfojaf u fexuuku ua fpaucnosuuuja ua eeuu u fpaucnnaufauuja ua eeucku eaneynu.
Baneynufe ce ce seuaaf op sppaeufe eeuu ua nauueufof.
Cknepofepanuja uoe pa ce kopucfu kako kounneueufapua ua xupyprujafa. (nnp-D)
Peqnykcof ce npeeeuupa no naf ua uujekfupane ua ckneposupaku areuc eo eeuafa.
Tpefuauof e epsau co nojaea ua kounnukauuu u eo uekou seuju ue e eo qpekqeufua
ynofpea.
Bencxu ynuepauuu na nora1a
Tpefuauof e asupau ua ofcfpauyeane ua npuuuafa sa nokaeu eeucku npufucok.
Ynofpeafa ua konpecueuu opanu npep u no xupypukuof saqaf (nnp-C) e uunepa-
fueua.
Ako ynkycof ue nokayea suauu ua sasppaeyeane unu nopopyeane no fpuueceeu
kousepeafueeu fpefuau, nofpeua e koucynfauuja op nnacfueu xupypr.
PEOEPEHUH
Donnelly R, Hinwood D, London N. Non-invasive methods of arterial and venous
assessment. BMJ 2000;320:698701
London N, Nash R. Varicose veins. BMJ 2000;320:13914
Sybrandy JE, ym. Endoscopic versus open subfascial division of incompetent perforating
veins in the treatment of venous leg ulceration: Long-term follow-up. J Vasc Surg
2001;33(5):102832
EBM GuideIines 22.11.2004 www.ebm-guideIines.com
Yna1c1no1o 1pea pa ce axypupa epnam na 4 ropunu
Rpepnupeno cnepno axypupane po noeunpu 2008 ropuna

1.
2.
3.
1.
2.
3.
Tom 2.indb 703 25.05.2006 10:34:17
704 YRATCTBA 3A RPAKTHKYBAhE MEHUHHA 3ACHOBAHA HA OKA3H
Tom 2.indb 704 25.05.2006 10:34:17