Yongo At medi 2008;51:11 15 Vuum-Assisted Closure (VAC) for Bilterl Severe Ishemi Foot fter Revsulriztion: A Ptient Report Kengo Nishimur, Ysushi Knok, Shingo Hrd, Munehiro Siki, Akir Mrumoto, Yoshinou Nkmur nd Motonou Nishimur Division of Orgn Regenertion Surgery, Deprtment of Surgery, Shool of Mediine, Tottori University Fulty of Mediine, Yongo 683-8053 Jpn The Vuum-Assisted Closure (VAC) Therpy (KCI, Sn Antonio, TX) is unique system tht helps promote wound heling. We report se of severe ishemi foot in whih VAC therpy mrkedly improved wound heling. A 73-yer-old mn underwent left xillopoplitel ypss nd left 3rd, 4th nd 5th digitl mputtions for gngrene. Although his mputtion stumps were omplited with methiillin-resistnt Stphyloous ureus (MRSA) infetion, the stumps were suessfully heled y VAC. He lso hd gngrene in his right 1st toe, whih ould not heled y VAC lone, nd we performed right femoropoplitel ypss nd right 1st digitl mputtion. The stump with MRSA infetion ws lso suessfully heled y VAC. Histopthologi exmintion reveled lot of mirovessels in the inresed grnultion tissue. Key words: peripherl orti disese; severe ishemi foot; vuum-ssisted losure Ptient Report The ptient ws 73-yer-old mn, who hd history of right ommon ili rtery-right ommon femorl rtery ypss in 1989. He hd een treted medilly for rest pin of his left foot in lol hospitl sine August, 2003. He ws referred to our hospitl on Novemer 22, 2005. Physil exmintion ws unremrkle exept for gngrene in prt of his left 3rd, 4th nd 5th toes s well s mild ulertion on the tip of his right 1st toe. No pulse ws identified in either lower extremity exept for the right femorl pulse. The Ankle Brhil Index (ABI) is mesure of the fll in lood pressure in the rteries supplying the legs nd s suh is used to detet evidene of lokges (peripherl vsulr disese). It is lulted y dividing the systoli lood pressure in the nkle y the higher of the two systoli lood pressures in the rms. His ABI ws 0.34 on the right side nd 0.31 on the left. Adominl omputerized tomogrphy showed tht dominl ort with severe lifition hd stenosis nd tht olusion of ilterl ommon ili rteries with ptent right ommon ili rteryright ommon femorl rtery ypss. Angiogrphy of the lower extremities showed the right superfiil femorl rtery ws oluded from its origin nd the poplitel rtery ws enhned y the rnh of the profound femorl rtery. The left superfiil femorl rtery ws lso oluded from its origin, nd the left profound femorl rtery nd left poplitel rtery were enhned y the rnh of the right profound femorl rtery. Bilterl peronel rteries, nd nterior nd posterior tiil rteries were ptent, lthough their wlls were irregulr. We deided to tret the ilterl severe ishemi foot due to rteriosleroti oliternse. Arevitions: ABI, Ankle Brhil Index; MRSA, methiillin-resistnt Stphyloous ureus; VAC, vuum-ssisted losure 11
K. Nishimur et l. Fig. 1. Altough we ontinued to disinfet nd wsh the open wound s usul for 30 dys, it underwent methiillinresistnt Stphyloous ureus (MRSA) infetion nd still remined open. : 11 postopertive dy. : 30 postopertive dy. : A disposle exudtes tue ws pled t the wound site nd polyurethne film filled the wound inluding the tue. Left lower extremity d Fig. 2. Effet of the Vuum-Assisted Closure (VAC) Therpy for the left leg. : Before VAC. : After 1 week of VAC. : After 4 weeks of VAC. d: After 14 weeks of VAC. As he hd rest pin with gngrene of the left 3rd, 4th nd 5th toes, revsulriztion of the left lower extremity nd the resetion of disesed toes were performed first. Under generl nesthesi, trnsverse inision of 10 m ws mde elow the left lvile nd longitudinl inision of 7 m ws mde in the left lower third of the thigh long the nterior order of the srtorius musle. Revsulriztion etween the left xillry rtery nd left proximl poplitel rtery ws performed with knitted Dron grft nd resetion of the left 3rd, 4th nd 5th distl phlnges, middle phlnx nd proximl phlnges with stumps open. There ws no ovious sess in the suutneous tissue round the distl phlnges. Postopertive ABI ws 1.07 on the left side. However, the stumps were omplited with methiillin-resistnt Stphyloous ureus (MRSA) infetion nd they still remined open 30 dys fter the opertion (Figs. 1 nd ). We deided to introdue VAC therpy fter pprovl y the Ethis Committee of Tottori University Fulty of Mediine. A disposle exudtes tue ws pled t the wound site nd polyurethne film ompletely overed the wound inluding the tue (Fig. 1). Continuous negtive pressure of round 125 mmhg ws pplied to the wound vi the tue. The polyurethne film nd tue were hnged twie week. VAC rpidly elerted wound losure in only one week. However, VAC 12
VAC for ilterl severe ishemi foot Fig. 3. There were lot of pillry vessels in the grnultion tissue tken from the left leg. The setion ws stined with hemtoxylin-eosin. The degree ws judged under light mirosope. The drk r represents 100 µm. grdully enhned wound losure therefter, nd the wound finlly losed in 14 weeks (Fig. 2). Histopthologi exmintion reveled proliferted mirovessels in the inresed grnultion tissue from the wound treted y VAC (Fig. 3). Right lower extremity Beuse the ptient wnted us to tret the gngrene in his right foot, we first tried VAC. However, VAC lone did not enhne wound losure for the ulertion on the tip of his right 1st toe. We deided on revsulriztion for the right lower extremity nd resetion of the toe, just s for the left side. We performed revsulriztion etween the right ommon femorl rtery nd right proximl poplitel rtery with n 8 mm knitted Dron grft nd resetion of the right 1st distl phlnges nd proximl phlnx inluding the neroti tissues. We kept the stumps open like the left lower extremity. Postopertive ABI ws 1.08 on the right side. VAC ws strted on the 4th postopertive dy nd it rpidly enhned wound losure in only 1 week in spite of MRSA infetion. However, VAC grdully enhned wound losure therefter. The wound finlly losed fter 6 weeks (Fig. 4). d Fig. 4. Effet of the Vuum-Assisted Closure (VAC) Therpy for the right leg. : Before VAC. : After 1 week of VAC. : After 4 weeks of VAC. d: After 6 weeks of VAC. Disussion The VAC Therpy hs een proven effetive in treting oth ute nd hroni wounds regrdless of infetion (Argent nd Morykws, 1997; MCllon et l., 2000; Armstrong nd Lvery, 2005; Cown et l., 2005). Hg et l. (2005) hve reported tht VAC is effetive for dieti foot wounds of ptients with theroslerosis. There were few reports on severe ishemi foot 13
K. Nishimur et l. in whih VAC fter revsulriztion filitted wound heling. The mehnism of VAC is onsidered in prt to t vi the redution of tissue edem, tht my ontin toxi y-produts of infetion nd prolonged inflmmtion, nd removl of ftors tht inhiit wound heling through the pplition of sutmospheri pressure with vuum (Argent nd Morykws, 1997; Morykws et l., 1997; MCllon et l., 2000), nd lso inrese lood supply nd redue the inidene of infetion in porine wound model (Morykws et l., 1997). Tissue teril ounts in infeted wounds were lso redued y 21% with VAC ompred with ontrols (Morykws et l., 1997). VAC my lso stimulte wound heling through the promotion of ell division, ngiogenesis, nd lol prolifertion of growth ftors (Sxen et l., 2004). Nishimur et l. (2006) hve reported tht the effet of high-frequeny repetitive streth or n intermittent streth on the ell prolifertion nd survivl of humn derml firolsts nd the tivtion of ny relevnt signl pthwys. In this se, histopthologi exmintion showed lot of mirovessels in the inresed grnultion tissue. Femorl-femorl-poplitel rtery ypss or right femorl-left poplitel rtery ypss should hve een onsidered initilly s n pproprite tretment. However, in the present se, euse the dominl ort hd stenosis nd we my need to do right xillo-femorl or femorlfemorl rtery ypss in the ner future, we performed left xillo-poplitel rtery ypss without exposure of the right femorl region. We lso performed open minor mputtion for fer of possile infetion, even though there ws no ovious sign of infetion. In the present se, VAC rpidly enhned wound losure in only one week in spite of MRSA infetion, nd grdully enhned wound losure therefter. The wounds losed in 14 weeks on the left side nd 6 weeks on the right side. Our se suggests tht VAC my e effetive even for infeted wounds, espeilly within the 1st week fter VAC strted. On the other hnd, s on the right side, this se lso suggested tht lot of mirovessels in the inresed grnultion fter VAC therpy my e relted to filitte wound heling s well s VAC my not e effetive when the lood supply is insuffiient. In treting ishemi foot with gngrene, revsulriztion should e performed first, efore pplying VAC therpy. Moreover, s we onfirmed the effetiveness of VAC on the left side, we hve hd etter erlier pply VAC on the right side, not ut the 4th postopertive dy. The enefit of VAC therpy is lso in its osteffetiveness. The polyurethne film nd tue were hnged only twie week. Whenever ptients wnt to leve their eds, VAC n e esily disonneted nd onneted one they go k to ed. This is why ptients don t hve to e totlly onfined to ed during VAC. Ishemi foot with gngrene n e treted only with revsulriztion, ut ptients lwys need disinfetion nd/or wshing s usul tretment in the hospitl for long period. VAC might possily shorten the length of hospitl sty. In some ses, VAC filed to enhne wound losure in spite of inresed grnultion tissue (Armstrong nd Lvery, 2005; Cown et l., 2005). Further studies re wrrnted regrding the following: i) wht is the indition for VAC?; ii) whih is etter, ontinuous or intermittent negtive pressure?; iii) how long should VAC ontinue? nd iv) how does VAC ffet superfiil wound? In onlusion, we report se of severe ishemi foot in whih VAC fter revsulriztion filitted wound heling in spite of MRSA infetion. Referenes 1 Argent LC, Morykws MJ. Vuum-ssisted losure: new method for wound ontrol nd tretment: linil experiene. Ann Plst Surg 1997;38: 563 577. 2 Armstrong DG, Lvery LA. Negtive pressure wound therpy fter prtil dieti foot mputtion: multientre, rndomised ontrolled tril. Lnet 2005;366:1704 1710. 3 Cown KN, Tegue L, Sue SC, Mhoney JL. Vuum-ssisted wound losure of deep sternl infetions 14
VAC for ilterl severe ishemi foot in high-risk ptients fter rdi surgery. Ann Plst Surg 2005;80:2205 2212. 4 Hg M, In M, Azum N, Aksk N, Kdohm T, Kokuo T, et l. Vuum-ssisted losure on dieti foot wounds of the ptients with theroslerosis. Jpn J Vs Surg 2005;14:689 693. 5 MCllon SK, Knight CA, Vliulus JP, Cunninghm MW, MCulloh JM, FrinsLP. Vuum-ssisted losure versus sline-moistened guze in the heling of postopertive dieti foot wounds. Ostomy Wound Mnge 2000;46:28 34. 6 Morykws MJ, Argent LC, Shelton-Brown EI, MGuirt W. Vuum-ssisted losure: new method for wound ontrol nd tretment: niml studies nd si foundtion. Ann Plst Surg 1997; 38:553 562. 7 Nishimur K, Blume P, Ohgi S, Sumpio BE. Effet of different frequenies of tensile strin on humn derml firolst prolifertion nd survivl. Wound Rep Reg 2006; 15: 645 656. 8 Sxen V, Hwng CW, Hung S, Eihum Q, Inger D, Orgill DP. Vuum-ssisted losure: mirodeformtions of wounds nd ell prolifertion. Plst Reonstr Surg 2004;1086 1098. Reeived Deemer 17, 2007; epted Jnury 9, 2008 Corresponding uthor: Kengo Nishimur, MD 15