The Vacuum-Assisted Closure Device as a Bridge to Sternal Wound Closure

Abstract

Sixteen patients were treated for sternal wound infections after undergoing cardiac procedures. Their management involved prompt surgical debridement and quantitative wound biopsies. At the time of the initial debridement, the Vacuum-Assisted Closure Device (V.A.C.) was placed in the open sternal wound. A subatmospheric environment was maintained by the device at a level of 75 to 150 mmHg. The V.A.C. sponge was changed every 2 to 3 days, and operative debridement was performed until quantitative biopsies showed resolution of infection or until systemic signs of sepsis had resolved. At this time the sternal wounds were closed with regional muscle flaps. Patients were excluded from the use of the device if the pleural cavity was entered during operative debridement. Fifteen of the 16 patients survived and went on to complete wound healing and discharge from the hospital (average length of stay, 16.7 days). One patient sustained a cardiac dysrhythmia during the muscle flap procedure and died. There were no complications related directly to the use of the V.A.C. It is the opinion of the authors that the V.A.C. offers several advantages over their traditional methods of treatment. They noted improvement in sternal wound stabilization during the perioperative period and a decreased need for paralysis and mechanical ventilation. Wound management was improved by avoiding the need to perform debridement or to make desiccating dressing changes to an open sternum. Moreover, they also think that this device may lessen the risk for ventricular rupture because of better control of the wound environment and markedly improved stabilization of the debrided sternal elements.

Sternal Stability at Different Negative Pressures During Vacuum-Assisted Closure Therapy

“…4F-H). The most commonly used negative pressure in VAC therapy for poststernotomy mediastinitis is -125 mm Hg [14][15]. The use of -125 mm Hg is based on small-animal studies on peripheral wounds [10][11].…”

Staphylococcus aureus-Associated Musculoskeletal Infections

“…Furthermore, it is important to take samples for microbiological analysis. The thoracic wound can be either treated open with a vacuum sealing bandage or, if closed, with a suction rinse system (Agarwal et al 2005;Doss et al 2002;Hersh et al 2001;Milano et al 1999). Restabilization of the sternum can be achieved by wiring according to Robicsek (Losanoff et al 2002;Robicsek et al 1977).…”

Vacuum-Assisted Closure of a Complex Pilonidal Sinus

“…4 Vacuum-assisted closure employs open-cell foam dressing with controlled subatmospheric pressure applied by means of a vacuum pump (125 mmHg below ambient pressure). [5][6][7] The device is ideally used continuously, and the dressings are changed every two to three days. 8 The device has been used to assist closure of complicated or chronic wounds, degloving injuries, infected or devitalized tissue wounds, burn injuries, and for wounds with exposed tendons.…”

“…[8][9][10] More recently, the device has been used in infected joint replacement, sternal wound infections, saphenous vein donor-site complications, and for the closure of cutaneous gastrointestinal fistulas. 7,10,11 The theory underlying use of subatmospheric pressure is that most (80-90 percent) wound closure is caused by wound contraction achieved by fibroblasts and myofibroblasts. The vacuum device assists wound contraction by exerting a centripetal force.…”

“…6,8 Furthermore, it avoids the need for daily debridement and changing of desiccating dressings. 7 The disadvantages of using the vacuum assist device include the need for initial in-hospital stay, relative immobility and the cost of use (estimated at $47 U.S. per day based on hire of the vacuum pump).…”