Venous leg ulcer is a burden for the patient as well as for the surgeons.

1. Update on negative pressure wound
therapy for venous leg ulcer.
Dr. Shantonu Kumar Ghosh
MBBS, MS (CVTS)
Assistant Professor (Vascular Surgery), National Institute of Cardiovascular Diseases
‘Vasculocare’, Trauma Center, Shyamoli, Dhaka, Bangladesh
Secretary for International Affairs, Bangladesh Vascular Society (BVS)
Contact- +8801715405567, E-mail- shantonukumarghosh@gmail.com
Website- www.vasculocare.com
Facebook- www.facebook.com/vasculocare

2. • Nothing to disclose

3. LEG ULCER
• A leg ulcer is discontinuity of the squamous
epithelium of the skin of leg
• Leg ulcers are a common, chronic, recurring
condition
• Prevalence- 1.5 to 3 per 1000
• Increases with age.
• Following healing, re-ulceration rates at one year
range from 26% - 69%

4. Chronic venous ulceration is a break in the skin,
present for more than 6 weeks, between the knee
and ankle joints, commonly over malleoli and tibial
tuberosity.
VE NOUS LEG ULC E R
It is the result of
sustained ambulatory
venous hypertension
due to CVI, causing
irreversible skin
damage

5. Ulcer Classification: Aetiology
• Vascular
– Venous: CVI, Varicose vein, Post sclerotherapy
– Arterial
– Lymphatic
• Infective
• Traumatic
• Neoplastic
• Systemic metabolic
• Neuropathic

6. Classification: Widmer’s
• Grade I : Teleangiectasias beyond the inner ankle,
‘corona phlebectatica’
• Grade II : Indurated edema, eczema,
dermatoliposclerosis, hyperpigmentation
• Grade III : Active or healed ulcer

7. Classification: CEAP
• Clinical Class 5-
healed ulceration
• Clinical Class 6-
active ulceration

8. Pathophysiology
• Deep vein thrombosis, perforator insufficiency,
superficial and deep vein insufficiencies,
arteriovenous fistulas and calf muscle pump
insufficiencies lead to increased pressure in the
distal veins of the leg and finally venous
hypertension.
Ambulatory venous pressure
Normal- <25 mm Hg
> 30 mm Hg- increased incidence
31 – 40 mm Hg- 15% possibility
> 90 mm Hg- 100% possibility

9. • Increased venous pressure leads to elevation of
pressure in capillaries.
• Allows the large molecules and cells to escape
into the interstitial fluid.
• Accumulation of blood cells and fibrinogen
deposits inhibit collagen production and plugging
of the capillaries leads to tissue ischemia.
• Secretion of growth factors, cytokines and matrix
metalloproteinases are deregulated.
• All these unfavorable factors disrupt the skin’s
microcirculation, stimulate inflammation and
create a non-healing environment.
Pathophysiology (contd.)

10. Risk factors
• obesity
• immobility
• trauma
• older age
• female sex
• congenital absence of veins
• deep vein thrombosis (DVT), phlebitis, and factor
V Leiden mutation.

11. Management of Venous Ulcer: Goal
decrease venous hypertension and restore regulation
of venous flow
• extremity elevation
• compression bandaging
• vascular surgical intervention
• Local treatment should follow “TIME” protocol
T – tissue debridement,
I – infection and inflammation control
M – moisture balance
E – epidermalization stimulation

12. Negative pressure wound therapy
(NPWT)
also known as
 vacuum assisted closure (VAC)
 foam suction dressing
 subatmospheric pressure dressing (SPD)
 vacuum pack therapy
 vacuum sealing technique(VST)
 sealed surface wound suction (SSS)
 sealing aspiration therapy

13. NPWT facilitates-
• wound cleansing
• establishes fluid balance by removal of exudate
from the wound
• provides moist environment
• reduces edema and third space fluid
• reduces bacterial colonization
• improves microcirculation
• stimulates granulation tissue formation
Negative pressure wound therapy

14. • 1st documented case during 400BC –
the Greeks practiced cupping using heated
copper bowls.
• Hippocrates and his followers used “collection
vessels” whose openings were heated and
applied directly over wounds to draw out and
collect blood and fluids.
History of NPWT

15. • By the end of the 19th century, Professor August
Bier defined the concept of cupping by a method
of igniting alcohol within a glass and placing a
rubber tube on the skin prior to application of the
heated cupping glass.
• Since 1908, Bier’s hyperemic treatment method
has been used for the treatment of all types of
open wounds (traumatic, chronic, and
postoperative) as well as for the treatment of
infections.
History: contd.

16. • In 1907, Dr. E. Klapp first used a suction pump for
removal of infectious materials in tuberculous
lesions in patient with advanced tuberculosis.
History: contd.

17. In 1952, the use of
NPWT with natural
sponge, foam rubber,
rubber sponge,
cellulose sponge,
gauze, cotton, and
other filler materials
was patented in
Germany.
History: contd.

18. Indications
• Acute wounds
• Full-thickness surgical wounds
• Chronic wounds
– Stage 3 pressure ulcers
– Stage 4 pressure ulcers
– Diabetic ulcers
– Venous stasis ulcers
• Traumatic wounds
• Dehisced wounds

20. Role of NPWT in wound healing
NPWT promotes wound healing through multiple
actions
• removal of exudate from the wounds to help
establish fluid balance
• provision of a moist wound environment
• reduction in edema and third-space fluids
• potential decrease in wound bacterial load
• an increase in the blood flow to the wound
• the promotion of white cells and fibroblasts
within the wound

21. Procedure
A wound vacuum system
has several parts.
A foam or gauze dressing
is put directly on the
wound.
An adhesive film covers
and seals the dressing and
wound.
A drainage tube leads
from under the adhesive
film and connects to a
portable vacuum pump.

22. The treatment requires a vacuum source to create a
continuous or intermittent form of negative pressure
inside the wound. Doing so removes fluid and
exudates infectious materials to aid in wound healing
and closure
Procedure

23. Procedure

24. The pump removes air pressure over the wound. It
may does this either constantly, or it may do it in
cycles.
Procedure

25. Visiting Nurse
Home caregivers
patients able to apply
and remove V.A.C.
Application of the V.A.C.
Procedure

26. Complications
Rare-
• Bleeding (which may be severe)
• Wound infection

27. Risk factors
• Exposed organs or blood vessels
• High risk of bleeding from another health problem
• Nearby bone infection
• Dead wound tissue
• Cancer tissue
• Fragile skin, such as from aging or longtime use of
topical steroids
• Allergy to adhesive
• Very poor blood flow to the wound
• Wounds close to joints that may reopen due to
movement

28. Monitoring and Progression of Wound
Healing
• Weekly wound measurement
• Signs of healing
– Oozing of blood as granulation tissue grows
– Wound bed becomes more red
– Gradual decrease in wound drainage
– Reduction in size of wound
• Average length of treatment is 4-6 weeks

29. • Single center randomized control trial
• NPWT vs Conventional daily dressing
• Wound healing rate 13.1 and 2.8 mm²/day
• 68% ulcers had 90% healing in 30 days
Egyptian Journal of Surgery, 2018
Study results:

30. • Single center study, 15 patients
• NPWT used on ulcer surface area >50cm².
• Mean treatment time was 9 weeks.
• Complete wound healing in all patients.
Biomed Research International, 2014
Study results:

31. • Retrospective chart
review of 1032
Medicare home
care patients
• 61% faster healing
rate
• 38% less cost
Ostomy/Wound Management, 1999
Study results:

32. * 300 wounds treated
(acute, subacute, and
chronic)
* 296 wounds improved
with an  rate of granulation
tissue formation
* Wounds were treated until
completely closed, split-
thickness skin graft applied,
or flap rotated
Annals of Plastic Surgery, 1997
Study results:

33. Source:
• Bennett JA. Negative Pressure Wound Therapy for Wound Treatment.,
Today's Geriatric Medicine Vol. 9 No. 6 P. 24
• Dominik A. Jaguścik R, Porzeżyńska J et. al. Large Venous Ulcers Treated
with Negative Pressure Wound Therapy– Case Report. Negative Pressure
Wound Therapy. Vol. 1, No. 3, July 2014. ISSN: 2334-184X (Print) / 2334-
1858 (Online). http://www.researchpub.org/journal/npwt/npwt.html
• Bollero D, Driver V, Glat P et al. The Role of Negative Pressure Wound
Therapy in the Spectrum of Wound Healing, Ostomy Wound Management.
2010; 56 (5 Suppl):1–18.
• Skin and Wound Care, Negative Pressure Wound Therapy Section 6 of 7 RN
and LPN Self-learning Module, DMC Adv Wound Care and Specialty Bed
Committee 2009.
• Kucharzewski M, Mieszczanski PB, Kucharzewska KW et al. The Application
of Negative Pressure Wound Therapy in the Treatment of Chronic Venous
Leg Ulceration: Authors Experience, Hindawi Publishing Corporation
BioMed Research International Volume 2014, Article ID 297230, 5 pages
http://dx.doi.org/10.1155/2014/297230