{"id":506,"date":"2023-05-17T22:20:58","date_gmt":"2023-05-17T19:20:58","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=506"},"modified":"2023-05-17T22:20:59","modified_gmt":"2023-05-17T19:20:59","slug":"yaslilarda-periferik-arter-hastaligi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yaslilarda-periferik-arter-hastaligi\/","title":{"rendered":"Ya\u015fl\u0131larda Periferik Arter Hastal\u0131\u011f\u0131"},"content":{"rendered":"\n

Ya\u015fla birlikte s\u0131kl\u0131\u011f\u0131 artan periferik arter hastal\u0131\u011f\u0131 (PAH) \u00e7o\u011funlukla ateroskleroz zemininde geli\u015fir. PAH hastalar\u0131nda bu nedenle serebrovask\u00fcler hastal\u0131k ve koroner arter hastal\u0131\u011f\u0131 riski de y\u00fcksektir. Ba\u015fl\u0131ca risk fakt\u00f6rleri ileri ya\u015f, t\u00fct\u00fcn kullan\u0131m\u0131, diyabetes mellitus, hipertansiyon, hiperlipidemi ve hipotiroidizmdir. PAH hareket kabiliyeti azalan ya\u015fl\u0131 hasta grubunda semptomlar\u0131n\u0131 gizleyebilmekle birlikte bozulmu\u015f y\u00fcr\u00fcme fonksiyonu, anormal ekstremite nab\u0131z muayenesi, solukluk, vask\u00fcler \u00fcf\u00fcr\u00fcm, iyile\u015fmeyen yaralar tan\u0131y\u0131 destekleyen bulgulard\u0131r. Tan\u0131da ilk tetkik ayak bile\u011fi-kol indeksidir, fakat s\u0131kl\u0131kla Doppler ultrasonografi (USG) ilk tan\u0131sal g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemi olarak kullan\u0131lmaktad\u0131r. USG\u2019de lezyon tespit edilirse anjiyografi yap\u0131lmaktad\u0131r.<\/p>\n\n\n\n

Tedavide klinik semptomlar\u0131n iyile\u015ftirilmesi ve hastan\u0131n sa\u011f kal\u0131m\u0131n\u0131n artt\u0131r\u0131lmas\u0131 hedeflenmektedir. En ba\u015fta yap\u0131lmas\u0131 gereken mevcut risk fakt\u00f6rlerinin kontrol alt\u0131na al\u0131nmas\u0131d\u0131r. Sigaran\u0131n b\u0131rakt\u0131r\u0131lmas\u0131, tansiyonun d\u00fczenlenmesi, kan \u015fekerinin d\u00fczenlenmesi, hiperlipideminin d\u00fczeltilmesi yan\u0131nda antiagregan tedavi, silostozol tedavisi, ayak bak\u0131m\u0131, egzersiz program\u0131, ileri d\u00f6nemde giri\u015fimsel revask\u00fclarizasyon ve b\u00fct\u00fcn tedavi modalitelerine ra\u011fmen sonu\u00e7 al\u0131namazsa amputasyon temel tedavi y\u00f6ntemleridir.<\/p>\n\n\n\n

Giri\u015f   <\/h2>\n\n\n\n

Periferik arter hastal\u0131\u011f\u0131 (PAH) terimi s\u0131kl\u0131kla klinik olarak alt ekstremite arteryel sisteminin t\u0131kay\u0131c\u0131 patolojileri i\u00e7in kullan\u0131lmaktad\u0131r. PAH\u2019a ait en son k\u0131lavuzlar 2016 y\u0131l\u0131nda Amerikan Kardiyoloji Cemiyeti (AHA) ve 2017 y\u0131l\u0131nda Avrupa Kardiyoloji Derne\u011fi (ESC) taraf\u0131ndan g\u00fcncellenmi\u015ftir (1, 2).\u00a0Ateroskleroz zemininde geli\u015fen PAH s\u0131kl\u0131\u011f\u0131 ya\u015f artt\u0131k\u00e7a artmaktad\u0131r. S\u0131kl\u0131\u011f\u0131 70 ya\u015f \u00fcst\u00fc bireylerde %30\u2019a ula\u015fmaktad\u0131r (3).<\/p>\n\n\n\n

\n
\"\"<\/figure>\n<\/figure>\n\n\n\n

\u015eekil <\/strong>1<\/strong>.<\/strong> Ateroskleroz zemininde periferik arter hastal\u0131\u011f\u0131<\/p>\n\n\n\n

Bir acil hekiminin akut ve kronik iskemi ay\u0131r\u0131m\u0131n\u0131 yapmas\u0131 \u00f6nemlidir. Kronik iskemiye en yayg\u0131n olarak PAH neden olur. PAH \u00e7o\u011funlukla popliteal arter ve y\u00fczeyel femoral arter sulama alan\u0131n\u0131 etkilemesi nedeniyle bald\u0131r b\u00f6lgesinde klinik olu\u015fturmakta ve kesik topallamaya (kladikasyo intermittant) neden olmaktad\u0131r. Belirli bir y\u00fcr\u00fcme mesafesinde hissedilen iskemik a\u011fr\u0131n\u0131n istirahat ile ge\u00e7mesi, tekrar y\u00fcr\u00fcme sonras\u0131 ayn\u0131 mesafede ayn\u0131 a\u011fr\u0131n\u0131n ba\u015flamas\u0131 durumudur. Ya\u015fl\u0131 pop\u00fclasyon farkl\u0131 nedenlerle hareket kabiliyetlerinde azalma oldu\u011fu i\u00e7in bu \u015fikayeti tariflemeyebilir. Ayr\u0131ca kollateral dola\u015f\u0131m deste\u011fine sahip hastalarda semptom vermeyebilir. \u0130lerleyen ya\u015f ile birlikte aterosklerotik hastal\u0131klar\u0131n birlikte bulunma oranlar\u0131 giderek artmaktad\u0131r. PAH\u2019da en \u00f6nemli mortalite riski olu\u015fturan neden e\u015f zamanl\u0131 koroner arter hastal\u0131\u011f\u0131d\u0131r (4). PAH\u2019dan kaynaklanan kronik iskemi, kritik uzuv iskemisi olarak bilinen, uzvun canl\u0131l\u0131\u011f\u0131n\u0131 tehlikeye atma derecesine kadar ilerleyebilir. Kritik uzuv iskemisi akut veya kronik iskeminin sonucu olabilir ve genellikle progresif t\u0131kay\u0131c\u0131 PAH\u2019dan kaynaklan\u0131r ancak emboli, vask\u00fclit, vazospazm, kompartman sendromu veya travma ile ili\u015fkili in situ trombozdan da kaynaklanabilir. Akut ekstremite iskemisi, ekstremitenin perf\u00fczyonunda uzvun canl\u0131l\u0131\u011f\u0131n\u0131 tehdit eden ani bir d\u00fc\u015f\u00fc\u015f oldu\u011funda ortaya \u00e7\u0131kar ve semptomlar\u0131n ba\u015flamas\u0131ndan sonraki iki hafta i\u00e7inde tan\u0131mlan\u0131r. Akut iskemi trombotik, embolik, inflamatuvar, travmatik, anatomik veya iyatrojenik nedenlerin sonucu olabilir (Tablo-1) (5).<\/p>\n\n\n\n

Tablo <\/strong>1<\/strong>.<\/strong> Akut ekstremite iskemisinin embolik ve trombotik sunumlar\u0131.<\/p>\n\n\n\n

 <\/strong><\/td>Emboli<\/strong><\/td>Tromboz<\/strong><\/td><\/tr>
Anamne<\/strong>z<\/strong><\/td><\/tr>
A\u011fr\u0131 ba\u015flang\u0131c\u0131<\/td>Semptomlar\u0131n h\u0131zl\u0131 ba\u015flang\u0131c\u0131<\/td>Kladikasyo semptomlar\u0131n\u0131n ani k\u00f6t\u00fcle\u015fmesi<\/td><\/tr>
T\u0131bb\u0131 \u00f6zge\u00e7mi\u015f<\/td>Bilinen PAH \u00f6yk\u00fcs\u00fc yok \u00b1 AF, yak\u0131n zamanda MI, kapak hastal\u0131\u011f\u0131<\/td>Bilinen PAH ge\u00e7mi\u015fi \u00b1 Koroner arter hastal\u0131\u011f\u0131, serebrovask\u00fcler hastal\u0131k<\/td><\/tr>
Vask\u00fcler cerrahi \u00f6yk\u00fc<\/td>Genellikle yok<\/td>Genellikle var<\/td><\/tr>
Fizik muayene<\/strong><\/td><\/tr>
\u0130nspeksiyon<\/td>Alacal\u0131, belirgin s\u0131n\u0131r<\/td>Mavimsi, s\u0131n\u0131rlar\u0131 belirsiz<\/td><\/tr>
S\u0131cakl\u0131k<\/td>So\u011fuk<\/td>Serin<\/td><\/tr>
N\u00f6rolojik<\/td>Paralizi<\/td>Parestezi<\/td><\/tr>
Kar\u015f\u0131 ekstremite<\/td>Normal<\/td>Anormal nab\u0131z muayenesi, k\u0131llarda d\u00f6k\u00fclme, parlak cilt, kal\u0131nla\u015fm\u0131\u015f t\u0131rnaklar<\/td><\/tr>
En s\u0131k neden<\/td>Kardiyak tromboemboli<\/td>Plak r\u00fcpt\u00fcr\u00fc<\/td><\/tr>
En s\u0131k iskemik s\u0131n\u0131f<\/td>Hemen tehdit (IIb)<\/td>Marjinal tehdit (IIa)<\/td><\/tr><\/tbody><\/table><\/div><\/figure>\n\n\n\n

PAH S\u0131n\u0131flamas\u0131<\/em><\/strong><\/h3>\n\n\n\n

Periferik arter hastal\u0131\u011f\u0131 i\u00e7in s\u0131kl\u0131kla Fontaine ve Rutherford klinik s\u0131n\u0131flamalar\u0131 kullan\u0131lmaktad\u0131r (Tablo-2) (6). <\/p>\n\n\n\n

Tablo-<\/strong>2<\/strong>.<\/strong> Fontaine ve Rutherford klinik s\u0131n\u0131flamas\u0131.<\/p>\n\n\n\n

Fontaine<\/strong><\/td>Rutherford<\/strong><\/td><\/tr>
Evre<\/strong><\/td>Semptom<\/strong><\/td>Evre<\/strong><\/td>Kategori<\/strong><\/td>Klinik tan\u0131m<\/strong><\/td><\/tr>
I<\/strong><\/td>Asemptomatik<\/td>0<\/td>0<\/td>Asemptomatik<\/td><\/tr>
I <\/td>I<\/td>Hafif kladikasyo<\/td><\/tr>
I<\/td>II<\/td>Orta kladikasyo<\/td><\/tr>
IIa<\/strong><\/td>Aktiviteyi s\u0131n\u0131rlamayan aral\u0131kl\u0131 kladikasyo<\/td>I<\/td>III<\/td>\u015eiddetli kladikasyo<\/td><\/tr>
IIb<\/strong><\/td>Aktiviteyi s\u0131n\u0131rland\u0131ran aral\u0131kl\u0131 kladikasyo<\/td>II<\/td>IV<\/td>\u0130skemik istirahat a\u011fr\u0131s\u0131<\/td><\/tr>
III<\/strong><\/td>\u0130skemik istirahat a\u011fr\u0131s\u0131<\/td>III<\/td>V<\/td>Min\u00f6r doku kayb\u0131<\/td><\/tr>
IV<\/strong><\/td>\u00dclser veya kangrenden<\/td>III<\/td>VI<\/td>Maj\u00f6r doku kayb\u0131<\/td><\/tr><\/tbody><\/table><\/div><\/figure>\n\n\n\n

Risk Fakt\u00f6rleri<\/h2>\n\n\n\n

Periferik arter hastal\u0131\u011f\u0131 etyopatogenezinde ateroskleroz en temel nedendir. Risk fakt\u00f6rleri; ya\u015f, t\u00fct\u00fcn kullan\u0131m\u0131, diyabetes mellitus (DM), hipertansiyon (HT), hiperlipidemi, hiperhomosisteinemi ve hipotroidizm olarak s\u0131ralanabilir (\u015eekil-2). Ya\u015fl\u0131 hastalarda PAH i\u00e7in bu ba\u011f\u0131ms\u0131z risk fakt\u00f6rlerinden ya\u015f, her 1 y\u0131l i\u00e7in erkeklerde 1.05, kad\u0131nlarda 1.03 tahmini r\u00f6latif risk art\u0131\u015f\u0131na yol a\u00e7maktad\u0131r (7).<\/p>\n\n\n\n

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\"\"<\/figure>\n<\/figure>\n\n\n\n

\u015eekil-<\/strong>2<\/strong>.<\/strong> Periferik arter hastal\u0131\u011f\u0131 i\u00e7in risk fakt\u00f6rleri.<\/p>\n\n\n\n

Fizik Muayene ve Tan\u0131sal S\u00fcre\u00e7ler<\/p>\n\n\n\n

Kas atrofisi, k\u0131l kayb\u0131, ipsilateral ayak t\u0131rnaklar\u0131nda hipertrofik de\u011fi\u015fiklikler etkilenen ekstremitenin inspeksiyon bulgular\u0131d\u0131r. Fizik muayenenin en \u00f6nemli bile\u015feni periferik nab\u0131z muayenesidir. Alt ekstremiteler i\u00e7in femoral, popliteal, dorsalis pedis ve tibialis posterior nab\u0131z muayeneleri yap\u0131lmal\u0131d\u0131r. Hastada PAH\u2019dan \u015f\u00fcphelenildi\u011finde veya non-palpabl nab\u0131z s\u00f6z konusu oldu\u011funda PAH etkilenme d\u00fczeyinin dolayl\u0131 olarak saptanmas\u0131 i\u00e7in ayak bile\u011fi kol sistolik bas\u0131n\u00e7 indeksi (ABK\u0130) \u00f6l\u00e7\u00fcm\u00fc yap\u0131lmal\u0131d\u0131r. Bu \u00f6l\u00e7\u00fcm i\u00e7in her iki brakial b\u00f6lgeden sistolik tansiyon arteriyel \u00f6l\u00e7\u00fcm\u00fc yap\u0131ld\u0131ktan sonra alt ekstremitelerden de bald\u0131r b\u00f6lgesine sar\u0131lan man\u015fon ile distalde hem tibialis posterior hem de dorsalis pedis b\u00f6lgelerinden el doppler ultrasonografisi yard\u0131m\u0131yla sistolik bas\u0131n\u00e7 \u00f6l\u00e7\u00fcmleri yap\u0131l\u0131r. ABK\u0130 0.9\u2019un alt\u0131nda olan durumlar PAH olarak tan\u0131mlanmaktad\u0131r (8).<\/p>\n\n\n\n

Periferik arter hastal\u0131\u011f\u0131 tan\u0131s\u0131nda ileri tetkik s\u00fcre\u00e7lerine ge\u00e7ilmesine, hastada giri\u015fimsel veya operasyonel m\u00fcdahale endikasyonunun bulunup bulunmamas\u0131na g\u00f6re karar verilir. Revask\u00fclarizasyon planlanan hasta grubunda ileri inceleme i\u00e7in anjiografi (BT veya MR) yap\u0131l\u0131r.<\/p>\n\n\n\n

Tedavi <\/h2>\n\n\n\n

Tedavinin amac\u0131 uzuv ve ya\u015fam\u0131n korunmas\u0131, kan ak\u0131\u015f\u0131n\u0131n yeniden sa\u011flanmas\u0131 ve tekrarlayan tromboz veya embolizmin \u00f6nlenmesidir. PAH tan\u0131s\u0131 koyulduktan sonra t\u00fcm hastalarda ilk basamak tedavi risk fakt\u00f6rlerinin modifikasyonunun yap\u0131lmas\u0131d\u0131r. <\/p>\n\n\n\n

\u00d6yk\u00fc ve fizik muayeneye dayal\u0131 olarak tan\u0131dan \u015f\u00fcphelenildi\u011finde, hastaya IV heparin bolusu ve ard\u0131ndan s\u00fcrekli heparin inf\u00fczyonu yap\u0131lmal\u0131d\u0131r. Mevcut uygulama, 80-150 U\/kg unfraksiyone heparin IV bolus, ard\u0131ndan 18 U\/kg\/saat inf\u00fczyon (hedef aPTT ba\u015flang\u0131\u00e7 d\u00fczeyinin 2-2,5 kat\u0131na ula\u015f\u0131ncaya kadar), sistemik antikoag\u00fclasyonun amac\u0131 tromb\u00fcs\u00fcn yay\u0131lmas\u0131n\u0131 \u00f6nlemek ve d\u00fc\u015f\u00fck ak\u0131\u015f ve staz nedeniyle arteryel ve ven\u00f6z sistemlerde distal olarak trombozu inhibe etmektir. Damar cerrahisi kons\u00fcltasyonu veya tan\u0131sal g\u00f6r\u00fcnt\u00fcleme i\u00e7in beklerken heparin uygulama karar\u0131 geciktirilmemelidir. Ekstremiteye olan perf\u00fczyon bas\u0131nc\u0131n\u0131 artt\u0131rmak i\u00e7in hasta yatak istirahatine al\u0131nmal\u0131 ve ekstremite s\u0131cak tutulmal\u0131d\u0131r. Yeterli a\u011fr\u0131 kontrol\u00fc \u00e7ok \u00f6nemlidir ve hipovolemik hastada IV kristaloid s\u0131v\u0131larla res\u00fcsitasyon \u00f6nerilir. Hipoksik hastalar ek oksijen almal\u0131d\u0131r. Akut kalp yetmezli\u011fi ve aritmilerle ba\u015fvuran hastalar, uzuv perf\u00fczyonunu iyile\u015ftirmek i\u00e7in derhal tedavi edilmelidir.<\/p>\n\n\n\n

Oral antikoag\u00fclan gerekmeyen hastalar;<\/u><\/em><\/strong><\/p>\n\n\n\n

    \n
  • Asemptomatik PAH\u2019da<\/li>\n\n\n\n
  • ESC 2017 Periferik Hastal\u0131klar K\u0131lavuzu\u2019nda antiplatelet tedavi<\/u><\/em> \u00f6nerilmezken (1);<\/li>\n\n\n\n
  • AHA 2016 Periferik Hastal\u0131klar K\u0131lavuzu\u2019nda tekli antiplatelet<\/u><\/em> (asetilsalisilik asit (ASA) 75-325 mg veya klopidogrel 75 mg) tedavi \u00f6nerilir (2).<\/li>\n\n\n\n
  • ABK\u0130= <0,9 (S\u0131n\u0131f 2a)<\/li>\n\n\n\n
  • ABK\u0130= 0,91-0,99 (S\u0131n\u0131f 2b)<\/li>\n\n\n\n
  • Semptomatik PAH\u2019da<\/li>\n\n\n\n
  • ESC 2017 Periferik Hastal\u0131klar K\u0131lavuzu\u2019nda Semptomatik PAH\u2019da antiplatelet tedavi<\/em> verilmelidir (1).<\/li>\n\n\n\n
  • Revask\u00fclarizasyon yap\u0131lan hastalarda uzun s\u00fcreli tekli antiplatelet tedavi<\/em> (ASA 75-325 mg veya klopidogrel 75 mg)<\/li>\n\n\n\n
  • Perk\u00fctan periferik giri\u015fim yap\u0131lanlarda 1 ay ikili antiplatelet tedavi<\/em> (ASA 75-325 mg ve klopidogrel 75 mg) (S\u0131n\u0131f 2a)<\/li>\n\n\n\n
  • Cerrahi giri\u015fim yap\u0131lanlarda ikili antiplatelet tedavi<\/em> (ASA 75-325 mg ve klopidogrel 75 mg) veya oral antikoag\u00fclan (S\u0131n\u0131f 2b)<\/li>\n\n\n\n
  • AHA 2016 Periferik Hastal\u0131klar K\u0131lavuzu\u2019nda semptomatik PAH\u2019da ikili antiplatelet tedavi<\/em> (ASA 75-325 mg ve klopidogrel 75 mg) ve vorapaksar (anti-Xa) (S\u0131n\u0131f 2b) \u00f6nerilmektedir (2).<\/li>\n<\/ul>\n\n\n\n

    Oral antikoag\u00fclan kullanmas\u0131 zorunlu olan hastalar;<\/u><\/em><\/strong><\/strong><\/p>\n\n\n\n

      \n
    • Hasta asemptomatikse ve cerrahi giri\u015fim yap\u0131lm\u0131\u015fsa oral antikoag\u00fclan verilir (S\u0131n\u0131f 1).<\/li>\n\n\n\n
    • Oral antikoag\u00fclan alanlarda, perk\u00fctan periferik giri\u015fim yap\u0131lanlarda ilk 1 ay \u00fc\u00e7l\u00fc tedavi (ASA 75-325 mg, klopidogrel 75 mg ve antikoag\u00fclan) s\u0131n\u0131f 2a endikasyonla \u00f6nerilir. Bu hasta grubunda 1 ay sonras\u0131nda ise ikili antiplatelet tedavi (ASA 75-325 mg ve klopidogrel 75 mg) veya oral antikoag\u00fclan tek ba\u015f\u0131na s\u0131n\u0131f 2b endikasyonla \u00f6nerilir.<\/li>\n\n\n\n
    • Kanama riski y\u00fcksek olan ve oral antikoag\u00fclan kullan\u0131m\u0131 zorunlu olan hastalarda ise oral antikoag\u00fclan tek ba\u015f\u0131na s\u0131n\u0131f 2a endikasyonla \u00f6nerilir.<\/li>\n<\/ul>\n\n\n\n

      Revask\u00fclarizasyon Endikasyonlar\u0131<\/h2>\n\n\n\n

      Periferik arter hastal\u0131\u011f\u0131nda temel revask\u00fclarizasyon endikasyonlar\u0131 (9);<\/p>\n\n\n\n

        \n
      • \u0130stirahatte de iskemik a\u011fr\u0131,<\/li>\n\n\n\n
      • Ekstremitede a\u00e7\u0131k ve uzun s\u00fcredir iyile\u015fmeyen yara, <\/li>\n\n\n\n
      • G\u00fcnl\u00fck aktivitelerinde k\u0131s\u0131tl\u0131l\u0131\u011fa yol a\u00e7acak ciddiyette ve mesafede kesik topallama \u015fikayetinin olmas\u0131 <\/li>\n<\/ul>\n\n\n\n

        Aortailiak okluziv lezyonlarda;<\/u><\/em><\/strong><\/strong><\/p>\n\n\n\n

          \n
        • K\u0131sa okluziv lezyonlarda (\u00f6rne\u011fin <5 cm) endovask\u00fcler tedavi (S\u0131n\u0131f I)
          • Aortailiak okl\u00fczyonda aorta-bifemoral baypas (S\u0131n\u0131f 2a). <\/li><\/ul>\n
              \n
            • \u015eiddetli komorbitelerin varl\u0131\u011f\u0131nda uzun ve\/veya bilateral lezyonlarda endovask\u00fcler tedavi ilk stratejidir (S\u0131n\u0131f 2a). <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n

              \u0130liofemoral okluziv lezyonlarda; <\/u><\/em><\/strong><\/p>\n\n\n\n

                \n
              • \u0130liak stentleme ve femoral endarterektomi veya baypasdan olu\u015fan hibrid yakla\u015f\u0131m (S\u0131n\u0131f 2a).<\/li>\n<\/ul>\n\n\n\n

                Femoropopliteal okluziv lezyonlarda;<\/u><\/em><\/strong><\/strong><\/p>\n\n\n\n

                  \n
                • 25 cm\u2019nin alt\u0131ndaki k\u0131sa lezyonlarda <\/li>\n\n\n\n
                • Endovask\u00fcler tedavi ilk se\u00e7enek (S\u0131n\u0131f 1), <\/li>\n\n\n\n
                • Primer stent implantasyonu (S\u0131n\u0131f 2a) <\/li>\n\n\n\n
                • \u0130la\u00e7 kapl\u0131 balon veya stentler (S\u0131n\u0131f 2b)<\/li>\n\n\n\n
                • Stent i\u00e7i restenozlarda ila\u00e7 kapl\u0131 balon (S\u0131n\u0131f 2b)<\/li>\n\n\n\n
                • Ya\u015fam beklentisi 2 y\u0131l\u0131n \u00fczerinde olan ve otolog venin kullan\u0131labildi\u011fi 25cm\u2019nin \u00fczerinde s\u00fcperfisiyal femoral arter okl\u00fczyonunda cerrahi risk y\u00fcksek de\u011filse baypas cerrahisi \u00f6nerilir. <\/li>\n\n\n\n
                • Cerrahiye uygun olmayan 25 cm\u2019nin \u00fczerindeki lezyonlarda s\u0131n\u0131f 2b endikasyonla endovask\u00fcler tedavi \u00f6nerilir. <\/li>\n<\/ul>\n\n\n\n

                  \u0130nfrapopliteal okluziv lezyonlarda;<\/u><\/em><\/strong><\/strong><\/p>\n\n\n\n

                    \n
                  • Kritik bacak iskemisi varl\u0131\u011f\u0131nda (2 haftadan uzun s\u00fcren istirahat a\u011fr\u0131s\u0131, iskemik \u00fclserler veya kangren) baca\u011f\u0131 kurtar\u0131c\u0131 revask\u00fclarizasyon tedavisi endikedir. Bu lezyonlarda safen ven greftinin kullan\u0131ld\u0131\u011f\u0131 baypas s\u0131n\u0131f 1 endikasyonla \u00f6nerilirken endovask\u00fcler tedavi s\u0131n\u0131f 2a endikasyonla \u00f6nerilir.<\/li>\n<\/ul>\n\n\n\n

                    T\u00fcm hastalarda iyi bir ayak bak\u0131m\u0131n\u0131n ve hastaya \u00f6zg\u00fc haz\u0131rlanan bir egzersiz rehabilitasyon program\u0131n\u0131n sa\u011flanmas\u0131 \u00f6nemlidir.<\/p>\n\n\n\n

                    Geri d\u00f6n\u00fc\u015f\u00fcms\u00fcz a\u015famada etkilenmenin oldu\u011fu hastalarda demarkasyon hatt\u0131n\u0131n belirginle\u015fmesi sonras\u0131nda uygun seviyeden amputasyon ger\u00e7ekle\u015ftirilmelidir. Ya\u015fl\u0131 hastalar i\u00e7in amputasyon karar\u0131nda temel al\u0131nacak belirleyiciler i\u00e7erisinde, geri d\u00f6n\u00fc\u015f\u00fcms\u00fcz etkilenmenin varl\u0131\u011f\u0131n\u0131n yan\u0131nda cerrahi veya giri\u015fimsel m\u00fcdahalelerin \u00e7ok riskli olmas\u0131, ya\u015fam beklentisinin \u00e7ok d\u00fc\u015f\u00fck olmas\u0131, fonksiyonel k\u0131s\u0131tl\u0131l\u0131klar\u0131n ekstremite kurtar\u0131lmas\u0131n\u0131n avantaj\u0131n\u0131 ileri d\u00fczeyde azaltmas\u0131 durumlar\u0131 da say\u0131labilir. Klinik tedavi karar\u0131 al\u0131n\u0131rken t\u00fcm hastalar kendi \u00f6zelliklerine g\u00f6re de\u011ferlendirilmelidir (10).<\/p>\n\n\n\n

                    Prognoz<\/h2>\n\n\n\n

                    PAH bulunan hastalarda mortalite oranlar\u0131 y\u00fcksektir. ABK\u0130 \u00f6l\u00e7\u00fcm\u00fcne g\u00f6re PAH tan\u0131s\u0131 koyulan hastalarda kardiyovask\u00fcler mortalitede 3-6 kat art\u0131\u015f s\u00f6z konusudur.<\/p>\n\n\n\n

                    Sonu\u00e7<\/h2>\n\n\n\n

                    Periferik arter hastal\u0131\u011f\u0131 olan ya\u015fl\u0131lar i\u00e7in al\u0131nacak t\u00fcm klinik kararlarda hastan\u0131n ya\u015f\u0131ndan daha \u00f6nemli olan hastan\u0131n fizik kond\u00fcsyonu, mevcut klinik durumu ve hastan\u0131n beklenti d\u00fczeyidir.<\/p>\n\n\n\n

                     <\/h2>\n\n\n\n

                    Kaynaklar<\/h2>\n\n\n\n
                      \n
                    1. Aboyans V. Ricco JB. Bartelink MLEL. et al. ESC Scientific Document Group. The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017;39(9):763816.<\/li>\n\n\n\n
                    2. Gerhard-Herman MD. Gornik HL. Barrett C. et al. 2016 AHA\/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary. Vasc Med. 2017;22(3):NP1NP43.<\/li>\n\n\n\n
                    3. Co\u015fgun MS. ve De\u011firmenci H. Alt Ekstremite Periferik Arter Hastal\u0131\u011f\u0131na G\u00fcncel Yakla\u015f\u0131m. MN Kardiyoloji. 2020;27(4):245-249<\/li>\n\n\n\n
                    4. Khan S. Hawkins BM. Acute Limb Ischemia Interventions. Interv Cardiol Clin. 2020 Apr;9(2):221-228.<\/li>\n\n\n\n
                    5. Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909.<\/li>\n\n\n\n
                    6. Hardman RL. Jazaeri O. Yi J. Smith M. Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014;31(4):378-388.<\/li>\n\n\n\n
                    7. McNally MM. Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096.<\/li>\n\n\n\n
                    8. Gilliland C. Shah J. Martin JG. Miller MJ Jr. Acute Limb Ischemia. Tech Vasc Interv Radiol. 2017 Dec;20(4):274-280.<\/li>\n\n\n\n
                    9. Utsunomiya M. Endovascular Therapy for Acute Limb Ischemia. J Atheroscler Thromb. 2021 Nov 1;28(11):1126-1127.<\/li>\n\n\n\n
                    10. McNally MM. Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

                      Ya\u015fla birlikte s\u0131kl\u0131\u011f\u0131 artan periferik arter hastal\u0131\u011f\u0131 (PAH) \u00e7o\u011funlukla ateroskleroz zemininde geli\u015fir. PAH hastalar\u0131nda bu nedenle serebrovask\u00fcler hastal\u0131k ve koroner arter hastal\u0131\u011f\u0131…<\/p>\n","protected":false},"author":1185,"featured_media":509,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[],"class_list":["post-506","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/506","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=506"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/506\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/509"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=506"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=506"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=506"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}