Yonago Acta medica 2008;51:11–15

Vacuum-Assisted Closure (VAC) for Bilateral Severe
Ischemic Foot after Revascularization: A Patient Report
Kengo Nishimura, Yasushi Kanaoka, Shingo Harada, Munehiro Saiki, AkiraMarumoto, Yoshinobu Nakamura and Motonobu Nishimura
Division of Organ Regeneration Surgery, Department of Surgery, School of Medicine, Tottori
University Faculty of Medicine, Yonago 683-8053 JapanThe Vacuum-Assisted Closure (VAC) Therapy (KCI, San Antonio, TX) is a uniquesystem that helps promote wound healing. We report a case of severe ischemic foot in
which VAC therapy markedly improved wound healing. A 73-year-old man underwent
left axillopopliteal bypass and left 3rd, 4th and 5th digital amputations for gangrene. Although his amputation stumps were complicated with methicillin-resistant Staphylococcus aureus (MRSA) infection, the stumps were successfully healed by VAC. He also had
gangrene in his right 1st toe, which could not healed by VAC alone, and we performed
right femoropopliteal bypass and right 1st digital amputation. The stump with MRSA
infection was also successfully healed by VAC. Histopathologic examination revealed alot of microvessels in the increased granulation tissue.
Key words: peripheral aortic disease; severe ischemic foot; vacuum-assisted closureof the two systolic blood pressures in the arms. His
ABI was 0.34 on the right side and 0.31 on the left.
Abdominal computerized tomography showed that
abdominal aorta with severe calcification had a stenosis and that occlusion of bilateral common iliac
arteries with a patent right common iliac arteryright common femoral artery bypass. Angiographyof the lower extremities showed the right superficial
femoral artery was occluded from its origin and thepopliteal artery was enhanced by the branch of theprofound femoral artery. The left superficial femoral artery was also occluded from its origin, andthe left profound femoral artery and left popliteal
artery were enhanced by the branch of the rightprofound femoral artery. Bilateral peroneal arteries, and anterior and posterior tibial arteries werepatent, although their walls were irregular. We de-Patient Report
The patient was a 73-year-old man, who had a history of a right common iliac artery-right common
femoral artery bypass in 1989. He had been treated
medically for rest pain of his left foot in a local
hospital since August, 2003. He was referred toour hospital on November 22, 2005. Physical examination was unremarkable except for gangrenein part of his left 3rd, 4th and 5th toes as well as amild ulceration on the tip of his right 1st toe. Nopulse was identified in either lower extremity except
for the right femoral pulse. The Ankle Brachial
Index (ABI) is a measure of the fall in blood pressure in the arteries supplying the legs and as suchis used to detect evidence of blockages (peripheralvascular disease). It is calculated by dividing thesystolic blood pressure in the ankle by the higher

cided to treat the bilateral severe ischemic footdue to arteriosclerotic obliteranse.

Abbreviations: ABI, Ankle Brachial Index; MRSA, methicillin-resistant Staphylococcus aureus; VAC, vacuum-assisted
closure11K. Nishimura et al.

abcFig. 1. Altough we continued to disinfect and wash the open wound as usual for 30 days, it underwent methicillinresistant Staphylococcus aureus (MRSA) infection and still remained open. a: 11 postoperative day. b: 30 postoperative day. c: A disposable exudates tube was placed at the wound site and a polyurethane film filled the wound
including the tube.

Left lower extremity
As he had rest pain with gangrene of the left 3rd,
4th and 5th toes, revascularization of the left
lower extremity and the resection of diseased toes
were performed first. Under general anesthesia,
a transverse incision of 10 cm was made below
the left clavicle and a longitudinal incision of 7
cm was made in the left lower third of the thighalong the anterior border of the sartorius muscle.
Revascularization between the left axillary arteryand left proximal popliteal artery was performed
with a knitted Dacron graft and resection of theleft 3rd, 4th and 5th distal phalanges, middle phalanx and proximal phalanges with stumps open.
There was no obvious abscess in the subcutaneous
tissue around the distal phalanges.
Postoperative ABI was 1.07 on the left
side. However, the stumps were complicatedwith methicillin-resistant Staphylococcus aureus(MRSA) infection and they still remained open
30 days after the operation (Figs. 1a and b). We
decided to introduce VAC therapy after approvalby the Ethics Committee of Tottori University
Faculty of Medicine. A disposable exudates tube
was placed at the wound site and a polyurethane
film completely covered the wound including thetube (Fig. 1c). Continuous negative pressure ofaround 125 mmHg was applied to the wound via
the tube. The polyurethane film and tube werechanged twice a week. VAC rapidly accelerated
wound closure in only one week. However, VAC

abcdFig. 2. Effect of the Vacuum-Assisted Closure (VAC)
Therapy for the left leg. a: Before VAC. b: After 1
week of VAC. c: After 4 weeks of VAC. d: After 14
weeks of VAC.

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VAC for bilateral severe ischemic footaFig. 3. There were a lot of capillary vessels in the granulation tissue taken from the left leg. The section wasstained with hematoxylin-eosin. The degree was judged
under a light microscope. The dark bar represents 100µm.

b

gradually enhanced wound closure thereafter,
and the wound finally closed in 14 weeks (Fig. 2).
Histopathologic examination revealed proliferated
microvessels in the increased granulation tissue
from the wound treated by VAC (Fig. 3).

cRight lower extremity
Because the patient wanted us to treat the gangrene in his right foot, we first tried VAC. However, VAC alone did not enhance wound closurefor the ulceration on the tip of his right 1st toe.
We decided on revascularization for the right lower extremity and resection of the toe, just as forthe left side. We performed revascularization between the right common femoral artery and rightproximal popliteal artery with an 8 mm knitted
Dacron graft and resection of the right 1st distal
phalanges and proximal phalanx including the necrotic tissues. We kept the stumps open like theleft lower extremity.
Postoperative ABI was 1.08 on the right side.
VAC was started on the 4th postoperative day andit rapidly enhanced wound closure in only 1 weekin spite of MRSA infection. However, VAC gradually enhanced wound closure thereafter. The
wound finally closed after 6 weeks (Fig. 4).

dFig. 4. Effect of the Vacuum-Assisted Closure (VAC)
Therapy for the right leg. a: Before VAC. b: After 1
week of VAC. c: After 4 weeks of VAC. d: After 6weeks of VAC.

Discussion
The VAC Therapy has been proven effective intreating both acute and chronic wounds regardless of infection (Argenta and Morykwas, 1997;
McCallon et al., 2000; Armstrong and Lavery,
2005; Cowan et al., 2005). Haga et al. (2005)
have reported that VAC is effective for diabetic
foot wounds of patients with atherosclerosis.
There were few reports on severe ischemic foot13

K. Nishimura et al.

in which VAC after revascularization facilitatedwound healing. The mechanism of VAC is considered in part to act via the reduction of tissueedema, that may contain toxic by-products of infection and prolonged inflammation, and removalof factors that inhibit wound healing through theapplication of subatmospheric pressure with a vacuum (Argenta and Morykwas, 1997; Morykwas
et al., 1997; McCallon et al., 2000), and also increase blood supply and reduce the incidence ofinfection in a porcine wound model (Morykwas
et al., 1997). Tissue bacterial counts in infected
wounds were also reduced by 21% with VAC
compared with controls (Morykwas et al., 1997).
VAC may also stimulate wound healing throughthe promotion of cell division, angiogenesis, andlocal proliferation of growth factors (Saxena et al.,2004). Nishimura et al. (2006) have reported thatthe effect of a high-frequency repetitive stretch
or an intermittent stretch on the cell proliferationand survival of human dermal fibroblasts and theactivation of any relevant signal pathways. In thiscase, histopathologic examination showed a lot ofmicrovessels in the increased granulation tissue.
Femoral-femoral-popliteal artery bypass orright femoral-left popliteal artery bypass shouldhave been considered initially as an appropriate
treatment. However, in the present case, because
the abdominal aorta had a stenosis and we mayneed to do a right axillo-femoral or femoralfemoral artery bypass in the near future, weperformed a left axillo-popliteal artery bypass
without exposure of the right femoral region. We
also performed open minor amputation for fear ofpossible infection, even though there was no obvious sign of infection.
In the present case, VAC rapidly enhanced
wound closure in only one week in spite of MRSA
infection, and gradually enhanced wound closurethereafter. The wounds closed in 14 weeks on
the left side and 6 weeks on the right side. Ourcase suggests that VAC may be effective even forinfected wounds, especially within the 1st week
after VAC started. On the other hand, as on theright side, this case also suggested that a lot of

microvessels in the increased granulation after
VAC therapy may be related to facilitate woundhealing as well as VAC may not be effective when
the blood supply is insufficient. In treating ischemic foot with gangrene, revascularization shouldbe performed first, before applying VAC therapy.
Moreover, as we confirmed the effectiveness ofVAC on the left side, we have had better earlier
apply VAC on the right side, not but the 4th postoperative day.
The benefit of VAC therapy is also in its costeffectiveness. The polyurethane film and tube
were changed only twice a week. Whenever patients want to leave their beds, VAC can be easily
disconnected and connected once they go back tobed. This is why patients don’t have to be totallyconfined to bed during VAC. Ischemic foot withgangrene can be treated only with revascularization, but patients always need disinfection and/orwashing as a usual treatment in the hospital fora long period. VAC might possibly shorten thelength of hospital stay. In some cases, VAC failed
to enhance wound closure in spite of increased
granulation tissue (Armstrong and Lavery, 2005;
Cowan et al., 2005). Further studies are warranted regarding the following: i) what is the indication for VAC?; ii) which is better, continuous
or intermittent negative pressure?; iii) how longshould VAC continue? and iv) how does VAC affect a superficial wound?
In conclusion, we report a case of severe
ischemic foot in which VAC after revascularization facilitated wound healing in spite of MRSA
infection.
References
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Received December 17, 2007; accepted January 9, 2008
Corresponding author: Kengo Nishimura, MD

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