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Abstract

We would like to thank Dr. Brehm for his kind remarks about our paper regarding the use of vacuum-assisted closure (VAC) for graft preservation in patients with exposed grafts. His letter addresses the possibility of arterial “blow-out” associated with use of VAC, a complication we have (fortunately) not seen. Understanding this concern, we will emphasize a number of points that may reduce the risk of this life-threatening complication. 1The importance of controlling infection with radical débridement, culture-directed antibiotics, and serial wound explorations cannot be overemphasized, as this is a prerequisite for graft preservation. This is not only true for VAC systems but also for those in whom muscle flap is contemplated. Graft preservation (with VAC or muscle flaps) cannot be accomplished unless the bacterial load is minimized. Case selection for graft preservation is extremely important, and graft removal should be considered when eradication of infection is not achieved.2We do not advocate starting VAC therapy early after the initial débridement. In our series, VAC was begun on the third day after débridement in those with an exposed anastomosis. Before VAC placement, we use silver-containing gel for dressing changes. This allows daily inspection of the wound to assess the adequacy of débridement and ensure lack of a significant infectious process. The presence of VAC in the wound does not allow close monitoring of the wounds in this early period.3Once the VAC is placed, we use nonadhering dressings around the anastomosis and personally inspect the wound during each VAC change. The nonadherent dressing is used until the anastomosis is no longer visible in the wound. This practice stems from our hypothetical concern about direct trauma to the anastomosis from the VAC device. However, we believe that the most likely cause of arterial disruption associated with groin wound infections is arterial infection. As Dr Brehm concludes that the arterial blow-out in his patient was “possibly … due to the suction of the VAC system,” use of a nonadherent dressing around the anastomosis may reduce the risk of direct arterial trauma and subsequent bleeding. We agree with Dr Brehm’s conclusion that the VAC should be used in highly selected patients with infected and exposed grafts. Because anastomotic blowout is a possible complication of attempted graft preservation with exposed anastomosis, these patients should be carefully monitored in the acute care setting and discharged only after the anastomosis is fully covered with granulation tissue with no evidence of infection. Regarding “Preservation of infected and exposed vascular grafts using vacuum assisted closure without muscle flap coverage”Journal of Vascular SurgeryVol. 44Issue 1PreviewWe congratulate Dosluoglu et al for their excellent results using vacuum-assisted closure (VAC) therapy for the preservation of infected and exposed bypass grafts (J Vasc Surg 2005;42:989-92). We have used VAC therapy for >5 years with highly satisfactory results in similar cases. Full-Text PDF Open Archive