Venous Leg Ulcer Management

V.A.C.® Therapy Creates an Environment
That Promotes Wound Healing

Video Demonstration

Prepares the wound

bed for closure

• Promotes granulation
tissue formation

• Promotes perfusion
• Maintains a moist wound

environment
• Removes exudate and

infectious material
• Reduces edema
• Draws wound edges

together

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V.A.C.® Therapy Prepares the Wound
Bed for Closure

Macrostrain: The visible alteration that occurs when
negative pressure contracts the foam dressing and draws
the wound edges together.

– Decreases wound margins

– Removes exudate and infectious material

– Reduces edema

Maintaining a Moist Wound Environment: The occlusive
V.A.C.® Drape helps provide a moist wound environment
and protects the wound from external contamination.

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V.A.C.® Therapy Promotes

Granulation Tissue Formation and

Perfusion by Means of Microstrain

Microstrain: The deformation that occurs at the cellular level
when mechanical forces are applied.

– Stimulates cell proliferation V.A.C.® GranuFoam™

– Fibroblast migration

V.A.C.® GranuFoam™ Tissue Interaction
The open-cell, reticulated characteristics Gauze Fibers
of V.A.C.® GranuFoam™ Dressings allow
for conformation to the wound surface for Tissue Interaction
maximum tissue interaction.

Gauze Fibers
The large size of gauze fibers may
contribute to less microstrain magnitude
and distribution.

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V.A.C.® Therapy: Mechanisms of Action (MOA)
Combined Effects of Macrostrain and Microstrain

Macrostrain Microstrain
Visible alteration occurs
when negative pressure Tissue micro-deformation at
contracts the foam, drawing
the wound edges together the cellular level under negative
and removing fluid
• Decreases wound margins pressure leading to cell stretch
• Removes exudate • Cell proliferation
• Reduces edema • Fibroblast migration
• Removes infectious material • Results in granulation tissue

formation and perfusion.

1. Saxena V, et al. Vacuum-Assisted Closure: Microdeformations of Wounds and Cell Proliferation. Plastic and Reconstructive Surgery, 2004; 114(5): 1086-96.
2. Wilkes R, et al. Effects of Dressing Type on 3D Tissue Microdeformations During Negative Pressure Wound Therapy: A Computational Study. Journal of Biomechanical

Engineering, March 2009; 13(3): 031012-1-12.
3. Ingber DE, et al. Fibronectin Controls Capillary Endothelial Cell Growth by Modulating Cell Shape. Proceedings of the National Academy of Sciences of the US, 1990; 87:3579.
4. Greene AK, et al. Microdeformational Wound Therapy: Effects of Angiogenesis and Matrix Metalloproteinases in Chronic Wounds of 3 Debilitated Patients. Annals of Plastic

Surgery, April 2006; 56(4):418-422.
5. Chen CS, et al. Geometric Control of Cell Life and Death, Science, 1997; 276: 1425.
6. Huang S, et al. The Structural and Mechanical Complexity of Cell-Growth Control, Nature Cell Biology, 1999; 1: E131.
7. Ingber DE, et al. Cell Shape, Cytoskeletal Mechanics, and Cell Cycle Control in Angiogensis, 1995; 28: 1471.
8. McNulty AK, et al. Effects of negative pressure wound therapy on fibroblast viability, chemotactic signaling, and proliferation in a provisional wound (fibrin) matrix. Wound Repair

Regen, 2007; 15(6): 838-46.

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Microstrain Helps Enhance Cellular
Bio-responses*

Microtubules Cell membrane Activation of Pathways by
Microfilaments Shear Stress

Receptors

ECM proteins Cell Stretch

Saxena V. et al. PRS, 2004; 114(5):1086-96. Chen, et al., JBC. 274:18393-400, 1999

Microstrain can be translated to the Microstrain induces generation of
interior of the cell through integrins (cell secondary messengers involved in
surface receptors linked to extra cellular proliferation.
matrix)
*Finite Element Model

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Sequential Combinations: Designed to
Expedite Typical Sequenced Wound Healing
to Full Closure

Bioburden Wound contraction Epithelialization
Reduction Granulation filling

NPWT Acellular Human Dermis
Split-thickness Graft
Surgical
Debridement Bilayer Skin E5q6uivalent

or
Amputation

Ready for Closure

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V.A.C.® Therapy Clinical Efficacy
Demonstrated in VLU – STSG Trial

Study Population: Subjects with VLU ready to
undergo debridement

– Total- 10
– V.A.C.® Therapy- 5 patients

– Bolster STSG Wound Care Control- 5 patients

Primary Endpoint: Percentage of Complete Wound Closure

This trial was terminated because of poor accrual and
resistance to randomization to the non-NPWT group

7 Day graft take
NPWT 100%; Bolster 84%

3 month closure rate
NPWT 100% graft survival; Bolster 68%

Lantis JC, et al. V.A.C.® Therapy Appears to Facilitate STSG Take when applied to Venous Leg Ulcer. 2nd World Union of Wound Healing Societies’ Meeting, Paris,
France, July 9, 2004

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V.A.C.® Therapy Clinical Efficacy Demonstrated in
Skin Grafting

Author N Wound Type % Take Comments

Blackburn 1 3 Large Complex 95 Case series

Scherer 2 61 Heterogenous Only 3% Control group
regraft 19% regraft

Kober 3 54 Venous 93% 100% in DM,
Vidrine 4 92% and old pts
45 Radial forearm
Lantis 5 flap 94% 81% with
traditional
18 Venous bolster

1) Blackburn JH, 2nd, Boemi L, Hall WW, Jeffords K, Hauck RM, Babducci DR, et al. Negative – pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;
40(5): 453-7

2) Scherer LA, Shiver S, Chang M, Meridith JW, Owings JT. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch
Surg. 2002; 137(8);930-3; discussion 3-4.

3) Korber A, Franckson T Gabbe S, Dissemond J. Vaccum assisted closure device improves the take of mesh grafts in chronic leg ulcers. Dermatology
2008;216(3):250-6

4) Vidrine DM, Kaler S, Rosenthal EL. A comparison of negative-pressure dressings versus Bolster and splinting of the radial forearm donor site. Otolaryngol Head
Neck Surg. 2005; 133(3):403-6.

5) Ross R, Lantis J, Gendics C, Mendes M, Benvenisty A, Todd G. Outcomes of complex lower extremity wounds treated with split thickness skin grafts and vacuum
assisted closure: a case series and review of the literature. SAWC, San Diego, CA, April 2007.

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Experience with V.A.C.® Therapy -
Fast Wound Bed Preparation

V.A.C.® Therapy System Compared to
Control:

ƒ Yielded higher proportion of wounds ready to close at
10 days than compression therapy alone

ƒ More robust granulation tissue response at 10 days

Moist Wound Therapy Control:

ƒ Resulted in a greater proportion of patients undergoing
secondary amputation

ƒ Longer duration of wound presence

Ross R, Lantis J, Gendics C, Mendes M, Benvenisty A, Todd G. Outcomes of complex lower extremity wounds treated with split thickness skin grafts and vacuum
assisted closure: a case series and review of the literature. SAWC, San Diego, CA, April 2007

© 2011 KCI Licensing, Inc. All rights reserved. DSL#11-0136 59

Wound Bed Preparation

6-18 6-25

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Studies supporting the use of
V.A.C.® Therapy for VLU

• 60 hospitalized patients
randomized to:
– 30 V.A.C.® Therapy

ƒ Used for both wound bed
preparation and as bolster
for STSG

– 30 MWT
• Wound bed prep time 58.8%

shorter
• Median time to complete

healing was reduced by 35.6%

Veurstaek JD, et al. State-of-the art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted-closure (V.A.C.) with modern wound
dressings. J Vasc Surg. 2006;44.1029-38.

© 2011 KCI Licensing, Inc. All rights reserved. DSL#11-0136 61

Studies supporting the use of
V.A.C.® Therapy for VLU

• V.A.C.® Therapy
cut treatment
costs by 28.8%

• V.A.C.® Therapy
cut nursing time
by 39.9%

Veurstaek JD, et al. State-of-the art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted-closure (V.A.C.) with modern wound
dressings. J Vasc Surg. 2006;44.1029-38.

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Novel Applications of
V.A.C. Instill® Wound Therapy

• PATIENTS:

– Five patients with venous stasis ulcers greater than 200 cm2
– Colonized with greater than 105 bacteria
– Treated with the V.A.C. Instill® Therapy for 10 days with 12.5% Dakins

solution, instilled for 10 minutes every hour.
– Two patients had multi drug resistant pseudomonas, three with MRSA.

• RESULTS:

– All 5 had negative quantitative cultures, prior skin grafting 10 days after
initiation of V.A.C. Instill® Therapy.

• Discussion:

– Adequate delivery of bactericidal agents to the infected tissue can be very
difficult, especially while promoting tissue growth. By providing a single
delivery system for a bactericidal agent for a short period of time followed
by a growth stimulating therapy the VAC instill provides a unique
combination that appears to maximize wound bed preparation

Raad W, Lantis JC II,Tyrie L, Gendics C, Todd G. Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin
graft placement. Int Wound J.2010;7:81-85

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V.A.C. Instill® Wound Therapy:

Prepping a Pseudomonas Infected Leg for Primary Closure

Debride in OR 10 DAYS later with V.A.C. Instill®

STSG in OR 30 Days later

Raad W, Lantis JC II,Tyrie L, Gendics C, Todd G. Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin
graft placement. Int Wound J.2010;7:81-85

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Outcomes of STSG and V.A.C.® Therapy for
Treatment of Complex Lower Extremity
Wounds

Percentage Take

OTHER
(30.5%)

Ross R, Lantis J, Gendics c, Mendes D, Benvenisty A, Todd G. Outcomes of complex lower extremity wounds treated with split thickness skin grafts and vacuum assisted
closure. SAWC 2007, San Diego, CA, April 2007

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V.A.C.® Therapy and STSG –
Reported Potential Benefits

• Maintain moist wound environment 1,2
therefore maintaining osmotic gradients

• Equal application of force allowing for uniform
apposition with the wound bed, decreasing
potential for shear

• Possible increased angiogenesis by
microdeformation 3

1. Winter GD. Effect of air exposure an occlusion on experimental human skin wounds. Nature 1963;200:378-9.
2. Zuhali B, Aflaki P, Koyoma T, Fossum M, Reish R, Schmidt B et al. Meshed skin grafts placed upside down can take if dessication is prevented. Plast Reconstr Surg.

2010;125(3):855-65.
3. Scherer SS, Pietramaggiori G, Matthews JC, Prsa MJ, Huang S, Orgill DP. The mechanism of action of the vacuum-assisted closure device. Plast Reconstruct Surg.

2008;122(3):786-797.

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Chronic Lower Extremity Wound

(Mixed lower extremity wound, status post
revascularization, prior to debridement)

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Wound debridement in the operating room
with pulse irrigation and placement of
V.A.C.® Therapy

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Immediately post debridement

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Application of 0.015 inch STSG
meshed 1.5:1

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Application of non-adherent
layer over STSG

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