Negative Pressure Wound Therapy as a Salvage Procedure in Venous Congestion of Microsurgical Procedures

Jorge I. Quintero, MD; Laura L. Cárdenas, MD; Adriana C. Achury, MD; Daniela Vega-Hoyos, MD; Julio Bermúdez, MD, MSc, PhD

Disclosures

Plast Reconstr Surg Glob Open. 2021;9(8):e3725 

In This Article

Discussion

To prevent venous congestion, different anticoagulation therapies have been described, but none are currently accepted in the literature.[4] It is generally accepted in microsurgery that for one artery, two veins should be anastomosed to allow outflow. Another way to treat this complication is by using leeches, with major complications during and after their use. Recently NPWT has been established to treat venous congestion.[5–10] The main treatment initiated after venous congestion is observed is the exploration of microsurgical anastomosis, irrigation, thrombectomy, and new anastomosis; leeches are a very good option in this treatment.[11]

To our knowledge, there are fewer complications with the use of NPWT when venous congestion in a free flap is identified. The mechanical explanation for this is that the negative pressure allows tissue compression (decreasing the local edema and also reducing the pro-inflammatory response secondary to the intervention) and improves the neovascularization (decreasing the reperfusion ischemia ratio). With these microvascular events, the venous congestion seems to be unlikely, but attention should be given to assess if active bleeding is observed, whether the pedicle is injured, and whether an emergency surgery needs to be performed.[12–14]

Qiu[15] highly recommends NPWT as an incisional method to assess venous congestion. The device must be used exclusively after a mechanical obstruction of the microanastomosis is detected. Yu[16] described 137 free flaps in which he used the NPWT as an incisional therapy, leaving the NPWT about 5 days, with a constant pressure between −75 and −125 mm Hg with full integration. Agarwal[17] described that therapies using pressure as low as −25 mm Hg are unable to produce neovascularization and cannot decrease the number of bacterial colonies. Pressure as high as −500 mm Hg can lead to mechanical problems such as local deformation of the tissue and reduction of the the degranulation tissue. In this study, we used the continuous therapy in five patients, and the intermittent in four patients, and the pressure was between −50 and −125 mm Hg, with no differences in the final integration of the flap.

Chim[18] performed a clinical trial using free muscle transfer flaps during the reconstruction of lower limbs. Nine patients underwent NPWT immediately after the flap, and for the other group, he used a wet gauze. At the end of the follow-up, all the free muscle flaps that had NPWT showed a better and faster integration, lesser volume of the flap, and better inflow and outflow.

There are some major complications related to NPWT, including pain, arterial erosion leading to active bleeding, septic shock, and infection secondary to anaerobe bacteria.[13] We had no major complications in our series, attesting to the safety of this device. We identified that the NPWT applied after the diagnosis of venous congestion leads to a decrease in congestion—in particular, improving the outcomes and avoiding any extra reintervention at our institution.

The limitation of this case series is the number of patients and the lack of a control group. The patient population was heterogeneous and had immediate use of the NPWT after undergoing the surgical procedure or after the diagnosis of venous congestion, and after finger replantation (in two cases). Comparative prospective studies and randomized studies should be conducted in the future.

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