Negative Pressure Wound Therapy in the Treatment of Venous Leg Ulcers

In this video, Dr. Lantis provides an overview and additional details relating to his literature review, Use of Negative Pressure Wound Therapy for the Treatment of Venous Leg Ulcers. Additional authors of the review include Callie Horn, MD and Allegra Fierro, MD. Read the full article here.
 

Transcript:

Hello, I'm John Lantis. I'm a vascular surgeon in New York City.

We have recently written a paper that is a review article in regards to use of negative pressure in chronic venous wounds or the therapy of. Interestingly, I think everybody in wound care community is very, very familiar with negative pressure wound therapy, and we've been using it in general for over 20 years. However, it really has not been used extensively and in many ways not really studied extensively in venous leg ulcers.

With that in mind, the paper tries to run through the literature such as it is for venous leg ulcers, really starting with its use in a couple very small prospective randomized trials that were actually company-sponsored back in the early portion of this century. It looks at sort of 5 different usages of negative pressure wound therapy for treating chronic venous leg ulcers. Sort of working backwards, probably the one that gets the most attention is using negative pressure wound therapy in conjunction with skin graft. So we discussed that and we discussed the literature that supports that and experiences that support that. We also then discuss using negative pressure wound therapy with cellular tissue-based therapies for venous leg ulcers.

We also take a look at using it to prepare the wound bed or reduce the bacterial burden, and then possibly some of its other features such as managing the fluid in a chronic leg ulcer, especially of venous etiology. And in addition to that, we take a look at its ability to really prepare the wound and get it ready for closure. All that being said, we do still highlight that one has to treat the underlying pathophysiology. One needs to have a diagnosis that is correct, so you need to establish the clinical diagnosis, the etiology of the venous disease, the anatomy and the pathophysiology. And then we also discuss how to use negative pressure wound therapy with compression because obviously, compression remains a significant mainstay of treating patients with chronic venous insufficiency. And that's one of the other reasons probably that negative pressure has not been used extensively in venous leg ulcers is it's hard to figure out how to use negative pressure and compression simultaneously.

One of the reasons we really took a look at this was we have experience using negative pressure wound therapy for venous leg ulcers, and we internally have experience at our institution and we realized that not many people talk about it and not many people use it. So we wanted to take a look at the evidence that would support our use of it, of negative pressure, not just our own anecdotal experience. So the real [inaudible] of this working with my two fellows was to review the literature, see what the support was for what we were doing, and making sure that it made scientific sense, at least within the context of what has been studied.

I think the main result of the review that was surprising was the amount of evidence there was in support of the non-powered single-use negative pressure units. In other words, the mechanical negative pressure units. I was aware of this, but after looking through the entire compendium of the article, I was surprised by how much data really supported the mechanical negative pressure units that are disposable and showed that they are ... really all the studies that were done or that have been published anyway, that they were equally effective to our more traditional negative pressure units. I think that was the most surprising knowledge that we gained. It was one of those things where you've read a paper and you've read another paper and you've read another paper, but when you put it all together into one large assessment of the evidence supporting something, there was a significant amount of evidence to support mechanical, as we call it, single-use, although it's really mechanical disposable, but might be used for several weeks. And that was a very interesting outcome that we saw.

Well, I think the thing that needs to be researched in this area is actually using negative pressure really in conjunction with compression therapy to prepare the wound bed. Now, this is a problem that we see is obviously negative pressure in general is not used to wound closure. And we all know this, this has been a problem for negative pressure for 20 years because the Food and Drug administration in the United States looks at devices and products, et cetera, and looks at a, usually a yes/no closure endpoint, but really using this with a wound bed preparation with compression and then closing the wound. So I think the appetite has to be there to look at this in combination therapy, and I think most of readers probably know that really there's not a ... it's almost considered that it's off-label or not an indication to use compression therapy with negative pressure from a manufacturing FDA standpoint. However, most clinicians who do use negative pressure for venous leg ulcers do use it in conjunction with compression therapy.

So it's not a standalone therapy and it doesn't replace compression therapy. So you'd have to design a study that included the treatment of the underlying disease in conjunction with negative pressure, and that's a complex study, but it could be done.