Abstract


In the environment of diabetes and peripheral vascular disease (PVD), there is a high risk of incisional complications following amputation, including seroma, hematoma, infection, and dehiscence. Incisional negative-pressure wound therapy (iNPWT) is a novel application of negative-pressure wound therapy (NPWT) that may be able to mitigate these complications and reduce the need for revisional surgery (including higher-level major lower-extremity amputations). It may also facilitate an increased rate of healing and earlier return to function. iNPWT has been used successfully in high-risk patients to decrease complications. In highly comorbid patients receiving iNPWT for primary closure of abdominal wall reconstruction, incisional infection rates were reduced from 48% to 7% (p=0.029). Furthermore, the need for revisional surgery was significantly decreased in those treated with iNPWT (48% vs.7%, p<0.001), as was the rate of dehiscence (10.68% vs. 5.32%, p<0.001). Major lower-extremity amputations in the multi-comorbid patient have a 16% incidence of incisional dehiscence. Additionally, the rate of infection has been reported to be as high as 22%. Five-year mortality following major lower-extremity amputation is reported to be 50% or higher. This high mortality rate is due, in part, to wound-healing complications. iNPWT can potentially reduce these healing complications and mortality. As of yet, no prospective, randomized trial has shown reduced morbidity, earlier return to function, or reduced mortality with the use of iNPWT after a lower-extremity amputation. This review presents recent findings regarding the use of iNPWT. Further studies on this topic are needed.

Abstract


Infection and wound dehiscence are common complications after surgery and open surgical wounds are difficult to manage. Usually surgical incisions are closed by fixing the edges together. However, in case of significant tissue loss, infected surgical field, or particular cases, wounds may be left open. In recent years, negative pressure wound therapy (NPWT) has been widely used for management of various complicated wounds and to support postoperative tissue healing. Another emerging indication for NPWT, applied directly to the closed incisions, is to prevent infections or dehiscences in patients with increased risk of surgical-site complications (iNPWT). Furthermore, the combination of negative pressure with intermittent instillation of solution (NPWTi) seems to be effective in the treatment of a variety of complex wounds. Even if the role of NPWT in promoting wound healing has been largely accepted, there is a lack of evidence (few high-level clinical studies) regarding its effectiveness and further research is needed to better understand the mechanisms of action. This article contains a review of recent scientific and clinical research related to indications, contraindications, and mechanisms of action of NPWT to clarify current knowledge, technological evolutions, and future perspectives of devices.

Abstract


At least 15% of patients with critical limb ischemia are not candidates for standard revascularization. In this day and age, with new techniques—including retrograde access to the foot—and numerous angioplasty and atherectomy techniques available, the critical limb ischemia patient can still be faced without options. Distal bypass surgery may still remain the gold standard, and likely permits the patient to have the best options for healing, but carries significant comorbidities after undergoing the procedure. There are patients who do not have targets of interest in their foot for arterial revascularization and there are patients who have very poor conduit or are very poor candidates due to their medical comorbidities. Guidelines as to who should and should not undergo surgery—or even percutaneous revascularization—are starting to become more widely accepted. We are starting to see the tide change and there is interest in this cohort of patients. There are patients with no distal target that may benefit from an arteriovenous bypass, which is regaining popularity and can be done completely endovascularly. The patient that may be a very poor candidate for intervention may benefit from arterial counterpulsation therapy and/or topical oxygen therapy (which are commercially available). They may also benefit from placental stem cell injection, which is undergoing Phase II trial assessment. We will review the current literature as it surrounds these potential therapeutic interventions for patients with significant lower extremity ischemia who do not have standard revascularization options.