Portal de Periódicos da CAPES

The role of the vacuum-assisted closure therapy in the salvage of venous congestion of the free flap: case report

2008; Wiley; Volume: 5; Issue: 1 Linguagem: Inglês

10.1111/j.1742-481x.2007.00362.x

1742-481X

Fatih Uygur, Haluk Duman, Ersi̇n Ülkür, Bahattin Çeiköz,

Infectious Aortic and Vascular Conditions

International Wound JournalVolume 5, Issue 1 p. 50-53 Open Access The role of the vacuum-assisted closure therapy in the salvage of venous congestion of the free flap: case report Fatih Uygur, Corresponding Author Fatih Uygur F Uygur, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeyF Uygur, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeyE-mail: [email protected]Search for more papers by this authorHaluk Duman, Haluk Duman H Duman, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this authorErsin Ülkür, Ersin Ülkür E Ülkür, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this authorBahattin Çeiköz, Bahattin Çeiköz B Çeiköz, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this author Fatih Uygur, Corresponding Author Fatih Uygur F Uygur, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeyF Uygur, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeyE-mail: [email protected]Search for more papers by this authorHaluk Duman, Haluk Duman H Duman, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this authorErsin Ülkür, Ersin Ülkür E Ülkür, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this authorBahattin Çeiköz, Bahattin Çeiköz B Çeiköz, Department of Plastic and Reconstructive Surgery and Burn Unit, Gülhane Military Medical Academy and Medical Faculty, Haydarpaşa Training Hospital, Istanbul, TurkeySearch for more papers by this author First published: 03 January 2008 https://doi.org/10.1111/j.1742-481X.2007.00362.xCitations: 24AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Abstract Indications for vacuum-assisted closure (VAC) therapy described generally include acute, chronic, traumatic wounds and ulcers. Recent studies related to investigating new applications of VAC therapy have begun to be reported at literature in many aspects. We used this technique in a novel area. A 21-year-old man presented who suffered venous congestion in anterolateral thigh fasciocutaneous flap at the postoperative second day. Following two cycles of VAC therapy, 72 hours later, venous congestion disappeared. Application of VAC therapy to the flap helps removal of excess interstitial fluid because of increased pressure gradients. It seems that VAC therapy is an option in venous congestion when the interstitial pressure rises above capillary pressure. Introduction Flap necrosis is the most important problem for the reconstructive surgeon, and venous congestion plays an important role in flap necrosis. Prolonged obstruction of venous flow results in flap necrosis (1). Venous congestion of free flaps can be solved through various methods. At present, the primary treatment for total venous occlusion is surgical re-exploration to provide venous outflow. If the anatomic problem is not correctable, then leeching can be initiated (2). When the interstitial pressure increases capillary pressure, the capillary flow to the flap cannot be maintained, and it eventually results in flap necrosis. The Food and Drug Administration approved vacuum-assisted closure (VAC) therapy currently (3). It affects wound healing by applying controlled, localised, negative pressure and promotes circulation mainly to the wound bed, decreases bacterial counts and increases rate of granulation tissue formation in wounds. Indications for VAC therapy described include acute, chronic, traumatic wounds and ulcers (4–7). Recent studies related to investigating new applications of VAC therapy have begun to be reported at literature in many aspects (8). In this paper, we showed that VAC therapy was effective in venous congestion of free flap. Case A 21-year-old man with palmar contracture involving the right hand was operated to release the contracture hand. In operation, wide excision of palmar scars and contracture bands was performed. A 8- × 7-cm anterolateral thigh fasciocutaneous flap was transferred to cover the extensive composite defect. Arterial anastomosis was completed with end-to-side to radial artery and concomitant vein with cephalic vein in end-to-end fashion. Twenty-four hours after surgery, significant evidence of venous congestion was noted. The patient was taken back to the operating room, and the pedicle was inspected. No tension on the pedicle was noted, and no compression or kinking of the vessels was evident. With manipulation of the pedicle, spontaneous drainage of venous blood from engorged veins was noted. The flap was inset again, except for the lateral and medial portion were left open. Six hours later, significant venous congestion involving the entire flap was noted again. The patient was taken back to the operating room, and the flap was re-explored. Although the artery was enough to perfuse the flap on its own, venous return was insufficient; yet, partial occlusion determined 3 cm vein portion. This segment was excised, and venous anastomosis was renewed by using interpositional vein grafting. But venous congestion did not disappear at the postoperative period. We attempted to overcome venous congestion by using medicinal leeching. Leeching was begun and continued for 12 hours. But it did not solve the problem, and congestion was still persistent (Figure 1). Figure 1Open in figure viewerPowerPoint Severe congestion and impaired venous return. We decided to use VAC therapy as a salvage procedure. Vacuum dressings were placed over the flap, and 125 mmHg of vacuum suction were applied to the flap (Figure 2). VAC dressings were changed as infrequently as 36 hours. Thirty-six hours later, rate of return of venous congestion decreased dramatically (3, 4). Venous congestion disappeared mostly 72 hours later (Figure 5). Figure 2Open in figure viewerPowerPoint First application of vacuum dressings and suction. Figure 3Open in figure viewerPowerPoint Postsuction in the 36th hour. Figure 4Open in figure viewerPowerPoint Second application of vacuum-assisted closure dressing and suction. Figure 5Open in figure viewerPowerPoint Postsuction in the 72nd hour. There was 100% survival of the flap with no evidence of necrosis, and no revision has been required to date. The flap was healed uneventfully at the 8-month follow-up (Figure 6). Figure 6Open in figure viewerPowerPoint Postoperative 25th day. Discussion Venous occlusion in free tissue transfers continues to remain as a significant and often detrimental clinical problem. Thrombosis usually occurs at the venous anastomosis, which damages the microcirculation and results in arterial thrombosis and eventual tissue loss (9). Total venous occlusion can result from multiple causes, ranging from haematoma and twisting of the pedicle to anastomotic thrombosis (10). Regardless of the cause, it is usually the venous anastomosis that clots first, which backs up the microcirculation, resulting in arterial thrombosis and subsequent complete necrosis of the flap. It has been shown that acute venous occlusion is more detrimental than global arteriovenous occlusion (9). Congestion can be divided into total or partial lack of venous outflow. The primary treatment for partial venous occlusion is medicinal or chemical leeching. But total venous occlusion needs thromboembolectomy procedures or reanastomosis (11). If the interstitial pressure increases over capillary pressure, the capillaries flow to the flap tissue cannot be maintained, and necrosis is inevitable. There is limited clinical observation about VAC therapy-considered flap survival in literature because of venous insufficiency. The effect of applied vacuum on flap survival in a swine model was reported (12,13). In those studies, the latissimus dorsi muscle was elevated on its vascular pedicle, the vein and nerve were ligated and transected and the flap was replaced into its bed. For control flaps, a VAC foam dressing was placed over the flap, but no vacuum was applied. These muscles consistently died because of congestion by 24 hours after surgery. For treated flaps, vacuum dressings were placed over the flap, and 125 mmHg of vacuum suction were applied to the flap after increasing lag times. It was shown that it is possible to salvage the flap with an up to 5-hour delay before vacuum application. This same mechanism is responsible for the success of the vacuum technique for decompression of both muscle compartment and abdominal compartment syndrome (14,15). The main problem addressed in our case was the occasional occurrence of venous congestion throughout the entire flap. We applied conventional methods initially. First, we explored vessels, and then subsequently, venous anastomosis was renewed by using interpositional vein grafting. But venous congestion was not salvaged by interposition grafting. Although the artery was enough to perfuse the flap on its own, venous return was always insufficient. We attempted to overcome venous congestion by using medicinal leeching. Maintenance of outflow and drainage of congested blood from veins by medicinal leeching not allowed sufficient nutrient blood flow to sustain compromised tissue until neovascularisation occurs. We assumed that congestion was increased possibly because of high interstitial pressure. We propose that application of a controlled vacuum to the flap interface facilitates removal of excess interstitial fluid because of increased pressure gradients. VAC therapy physically results in a decrease in interstitial pressure. When the interstitial pressure falls below capillary pressure, the capillaries reopen and flow to the flap tissue is restored. There is still much to be performed to elucidate the possible mechanisms of action. This result was logical when the effects of VAC therapy were considered. The duration of therapy to improve flap survival is not known but would probably require 3–4 days; in the meanwhile, neovascularisation of the flap results in sufficient venous drainage. It is possible that the negative pressure applied by the VAC device could create compression on the vascular pedicle. With this compression, arterial insufficiency could develop. This would have to be considered when using a VAC device in combination with free tissue transfer. To prevent this event, we used VAC therapy ular side of flap. Conclusion It seems that VAC therapy may be an option when the interstitial pressure rises above capillary pressure. It will be necessary to determine the efficacy of this therapy in further clinical practices. We advise to perform conventional method initially; if venous congestion is persistent, VAC therapy can be substituted as a further treatment option. References 1 Hjortdal VE, Sinclair T, Kerrigan CL, Solymoss S. Venous ischemia in skin flaps: microcirculatory intravascular thrombosis. Plast Reconstr Surg 1994; 93:366. 2 Lineaweaver WC, O’Hara M, Stridde B, Valauri FA, Buncke HJ. Clinical leech use in a microsurgical unit: the San Francisco experience. Blood Coagul Fibrinolysis 1991; 2: 189. 3 Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38: 563– 77. 4 Joseph E, Hamori CA, Bergman S, Roaf E, Swann NF, Anastasi GW. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. Wounds 2000; 12: 60– 7. 5 Schuster R, Moradzadeh A, Waxman K. The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound. Am Surg 2006; 72: 129– 31. 6 Orgill DP, Austen WG, Butler CE, Fine NA, Horvath KA, Mihaljevic T, Song DH, Wolfe WG. Guidelines for treatment of complex chest wounds with negative pressure wound therapy. Wounds 2004; 16 Suppl B: 1– 23. 7 Tang ATM, Ohri SK, Haw MP. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg 2000; 17: 482– 4. 8 De Lange MY, Schasfoort RA, Obdeijn MC, Van Der Werff JFA, Nicolai JPA. Vacuum-assisted closure: indications and clinical experience. Eur J Plast Surg 2000; 23: 178– 82. 9 Kerrigan CL, Wizeman P, Hjortdal VE, Sampalis J. Global flap ischemia: a comparison of arterial versus venous etiology. Plast Reconstr Surg 1994; 93: 1485. 10 Urken ML, Weinberg H, Buchbinder D, Moscoso JF, Lawson W, Catalano PJ, Biller HF. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 1994; 120: 633– 40. 11 Akan M, Yıldırım S, Gideroglu K. Salvage of flaps with venous congestion. Ann Plast Surg 2001; 46: 456. 12 Schneider AM, Morykwas MJ, Argenta LC, Capizzi M. Muscle flap survival after complete venous occlusion by external application of a negative pressure device. Presented at the 41st Annual Meeting of the Plastic Surgery Research Council. St. Louis, June 14 1996. 13 Marks MW, Schneider AM, Capizzi M, Argenta LC. Muscle flap survival after complete venous occlusion by application of a negative pressure device. Presented at the 66th Annual Meeting of the American Society for Plastic and Reconstructive Surgery, San Francisco, September 2124 1997. 14 Yang CC, Chang DS, Webb LX. Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg. J Surg Orthop Adv 2006; 15: 19– 23. 15 Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma 2000; 48: 201– 6; [Discussion 206–7]. Citing Literature Volume5, Issue1March 2008Pages 50-53 FiguresReferencesRelatedInformation