Vacuum Assisted Closure: Recommendations for Use: A Consensus Document (2025)

Planning treatment

In all situations the underlying wound aetiology and comorbidities must first be addressed and treated. It is essential to optimise all aspects of the patient’s physical, nutritional and psychosocial wellbeing to ensure treatment is suitable and of maximum benefit.

Before starting VAC therapy it is important to define treatment aims, objectives and clinical endpoints (1). In some circumstances the objective will be to avoid further complications and to control symptoms, rather than to influence time to healing. Examples of clinical endpoints for VAC therapy include 50% volume reduction (3), 80% granulation tissue formation or complete closure.

In general, the key aims are to:

• • 

  remove exudate and reduce periwound oedema

• • 

  increase local microvascular blood flow/test vascularity

• • 

  promote formation of granulation tissue

• • 

  reduce complexity/size of the wound

• • 

  optimize the wound bed prior to and following surgery

• • 

  reduce complexity of surgical wound closure procedures (4).

In addition, the application of the VAC dressing system creates a closed, moist wound environment, which may act as a barrier to bacteria and patient/caregiver interference. VAC therapy may also help to promote patient independence, mobility and comfort.

VAC therapy in practice

To date almost all published clinical trials on topical negative pressure therapy (2) have used the V.A.C.^® Therapy* system. This fully integrated system incorporates a polyurethane (V.A.C.^® GranuFoam^® and V.A.C. GranuFoam Silver^®) or polyvinyl alcohol (V.A.C.^® WhiteFoam Dressing) foam dressing and a microprocessor controlled unit that establishes a uniform distribution of pressure across the entire wound. It is this specific system that is referred to throughout this document. For further information on the safe use of this system (including appropriate pressure and therapy settings) and relevant patient safety information, please go to www.kci‐medical.com or contact your local KCI representative.

*All trademarks and service marks designated herein are the property of KCI Licensing Inc., its affiliates and licensors.

Identifying responders to VAC therapy

In chronic wounds, it may be helpful to use the factors listed in Table 1 to assess whether the wound is likely to have a positive response to VAC therapy. It must be noted, however, that in many circumstances the patient/wound will not exhibit these attributes and yet VAC may still have an important role. A good example of this, is the diabetic foot ulcer (see page 3) where the patient often has multiple comorbidities and the wound has a poor blood supply.

For acute wounds, it is important to adequately debride the wound and follow recommended guidelines for specific wound types (e.g. dehisced sternal wounds) before commencing therapy.

Alert: There may be benefits to starting VAC therapy as early as possible. Delaying therapy may allow the wound to deteriorate before being treated effectively.

Evaluating treatment

It is important to review progress regularly. This will involve an accurate and reproducible method of wound measurement (5). If there is a reduction in wound area (e.g. around 15%) after 1 or 2 weeks (6), strong consideration should be given to continuing VAC therapy with ongoing clinical evaluation. Reassess again after a further week of therapy. If there is no improvement, discontinue VAC therapy and begin an alternative treatment. VAC therapy may be reconsidered at a later stage.

In chronic wounds, an effective general assessment measure is to:

• • 

  examine the wound margins for inflammation after the first application of VAC therapy. If there is increased inflammation consider discontinuing treatment

• • 

  re‐examine the wound margins for a thin white epithelium after the second and subsequent applications: this indicates healing

• • 

  evaluate the overall appearance of the wound bed. A beefy, granular appearance is a positive outcome, while a dusky bed indicates inadequate tissue perfusion. Granulation tissue should increase by around 3–5% per day.

Under ideal conditions (especially in the absence of infection), well perfused wounds will respond quickly (i.e. within 1 week) with evidence of granulation tissue formation. This can be used to test vascularity and suitability of VAC therapy.

Alert: Adverse reactions have, on occasion, been reported (e.g. adherence to deep tissue structures). These can often be avoided by following recommendations (see box on p. 1), involving appropriately trained staff and by developing effective communication strategies. Specialist involvement will be required in certain situations.

Factors to consider in the presence of infection:

• • 

  Debridement

• • 

  Antibiotic therapy

• • 

  Patient optimization

• • 

  Frequent patient/wound assessment

• • 

  More frequent dressing changes

• • 

  Appropriate pressure settings

• • 

  Periwound skin protection

• • 

  Fenestrated antimicrobial dressings

VAC therapy and wound infection

VAC therapy is not recommended as a stand‐alone treatment for wound infection. However, it may be used with extra caution in infected wounds as long as this is in addition to appropriate treatment of the infection (see box left).

In the presence of persistent infection or deterioration, or in wounds exhibiting no clinical progress towards healing (i.e. odour continues or becomes apparent), perform a thorough patient and wound reassessment (including microbiological investigations), discontinue VAC therapy and change treatment. Always consider whether systemic antibiotic therapy and/or appropriate debridement is required and treat the wound infection according to local protocols.

If infection develops during therapy, consider systemic antibiotic treatment and discontinue VAC therapy to allow monitoring of the wound. On specific occasions, an advanced modification of VAC therapy (V.A.C. Instill^®) may be considered for use in severely infected wounds (e.g. infected hip and knee implants and orthopaedic hardware). This involves instilling an appropriate fluid into the wound bed, such as a topical antibacterial solution (7).

Deep complex diabetic foot wounds

VAC therapy can be used in a number of ways to manage the complex diabetic foot wound:

• • 

  Reduce complexity/size – i.e. simplify the wound. In non‐infected, non‐ischaemic, deep complex diabetic foot ulcers, VAC therapy can be used to reduce the surface area of the wound by encouraging granulation tissue formation over exposed bone, tendon or tissue. This may help to avoid the need for skin grafting and/or flaps or to reduce the complexity of the subsequent surgical closure procedure 8, 9. A special dressing technique should be used to prevent further pressure damage in plantar wounds when applying VAC therapy (10).

• • 

  Promote deep healing – Experience has shown that on occasions VAC therapy can be used for longer periods in combination with other treatment modalities (e.g. systemic antibiotics) to allow complete healing of an underlying osteomyelitis before skin closure. This avoids the problem of ulcer recurrence with residual osteomyelitis (i.e. where skin heals before the underlying bone).

In poorly perfused wounds where revascularization is not possible, using VAC therapy for a trial period allows the clinician to observe the response to therapy and assess the viability of the tissue. Even when a positive outcome is unlikely, VAC therapy used in this way has shown unexpected and encouraging results. The clinician should strive for the most distal amputation level that achieves healing and a functional outcome (8).

Alert: VAC therapy is not recommended if the tissue is grossly infected; is ischaemic on presentation; or in the presence of untreated osteomyelitis.

NB:

There are currently no studies on using VAC therapy in poorly perfused wounds

Planning treatment

The planned duration of therapy for diabetic foot wounds will depend on the specific treatment goal. In many cases an initial 1 to 2‐week period of therapy is recommended. After this time, the wound should be evaluated for progress or deterioration, and:

• • 

  if progress is good – i.e. there is a daily increase in healthy granulating tissue formation, decreasing wound depth, a good blood supply and no infection – continue VAC therapy until the treatment goal is achieved

• • 

  if progress is poor or there is deterioration, consider alternative treatments or breaks (‘timeouts’) in VAC therapy. During this time the clinician should re‐evaluate perfusion, focus on optimizing medical therapy and use other wound modalities until the tissue quality improves. Often at this time VAC therapy can be successfully reinstated.

post‐surgery diabetic foot wounds

Randomized controlled trials (RCTs) support the use of VAC therapy for the following:

• • 

  after open partial foot amputation (from open toe/ray/to metatarsal level) (8)

• • 

  to aid fixation or bolstering of skin grafts (11).

Split‐skin grafting and bioengineered tissue replacements, particularly acellular matrices, have been used in combination with VAC therapy as a practical alternative to flap closure in deep complex wounds (11). VAC therapy promotes vascular perfusion, which has been shown to enhance skin graft take (12).

Superficial diabetic foot wounds

VAC therapy is not recommended as a first‐line treatment in superficial wounds. However it may be considered along with other advanced therapies where there has been a poor response to other treatments (i.e. effective offloading, management of infection and local dressings).

Alert: Use VAC therapy with caution if the TcpO₂ is between 20 and 30mmHg and there is impaired sensation (in such cases use lower pressure settings).


 Summary of key (SIGN level 1) studies of VAC therapy in diabetic foot ulcers 


Application to practice

Use VAC therapy only after any underlying disease has been diagnosed and managed and after appropriate debridement of non‐viable tissue

VAC therapy can be an effective adjunct to revascularization in diabetic foot wounds

VAC therapy should be used only after surgical drainage of any infection with conconmitant systemic antibiotic therapy according to local protocols

VAC therapy should be combined with effective offloading and good wound care

Inflammatory ulcers

In patients with inflammatory ulcers, VAC therapy can be used to enhance wound bed preparation before definitive surgical closure or delayed secondary healing. These patients historically have hard‐to‐heal wounds with high rates of skin graft failure. Ulcers may occur in the following situations:

• • 

  scleroderma

• • 

  systemic lupus erythematosus

• • 

  hypercoagulation disorders

• • 

  rheumatoid arthritis

• • 

  vasculitic conditions.

If the underlying clinical condition is resistant or inadequately treated, inflammatory ulcers will usually not heal despite optimal wound management. In addition, as treatment usually involves non‐steroidal anti‐inflammatory drugs, healing may be further impaired. In non‐infected ulcers, a short trial of VAC therapy can be considered to determine whether it is likely to be beneficial. VAC therapy should be applied for 1–3 days and then removed while the response is evaluated.

Complex therapy‐resistant ulcers

VAC therapy can be considered for complex therapy‐resistant leg ulcers including:

• • 

  highly exuding ulcers

• • 

  anatomically challenging ulcers (where the application and stabilization of dressings is difficult)

• • 

  wounds requiring skin grafting (VAC therapy is used here for preoperative wound bed preparation and postoperative graft stabilization).

Note: In a non‐healing chronic ulcer in which other treatments have not been successful, granulation tissue may not be seen for up to 2 weeks when using VAC therapy.


 Summary of key (SIGN level 1) study of VAC therapy in chronic leg ulcers 


NB:

For further information on staging/grading of pressure ulcers see www.npuap.org and www.epuap.org

Grade/stage 3 and 4 pressure ulcers

VAC therapy is recommended as a first‐line treatment for grade/stage 3 and 4 pressure ulcers in certain situations (15) and should be used as part of a comprehensive treatment plan. The entire base of the wound should be visible and examined before inserting the foam. These are often complex wounds with multiple tracts; if appropriate, the wound must be debrided prior to commencing VAC therapy, with excision of bony osteomyelitis, and be fully explored to allow access to all deeper extensions.

Alert: Failure to open subcutaneous wound spaces is a frequent cause of treatment failure.

Practical tips:

• • 

  VAC therapy is not a substitute for good basic care and should be combined with appropriate pressure redistribution and good skin care

• • 

  Insertion and removal of the foam dressing is easier in wounds > 2 cm

• • 

  For sacral pressure ulcers in close proximity to the anus, application of VAC therapy requires additional expertise

Optimizing the wound

VAC therapy can be used preoperatively to precondition wounds for reconstruction or to allow a smaller and/or less complex flap to be used. This may help to reduce the operative time, postoperative risk and donor site morbidity. The effect of VAC therapy should be assessed continuously for a period of up to two weeks. Duration of VAC therapy will be defined by the initial wound size and the available volume of tissue for reconstruction. Post‐surgery, VAC therapy may be used to manage small dehiscences as well as to improve perfusion of a marginally viable flap.

Improving mobility/symptom control

In patients who develop pressure ulcers following a major life event (e.g. a traumatic spinal cord injury in an active patient), frequent dressing changes and long‐term bed rest can have a critical impact on their sense of wellbeing. VAC therapy may allow patients to mobilize in a wheelchair earlier and to return to rehabilitation programmes more quickly. Further research is required.

Some patients with pressure ulcers, such as those who have had multiple flap reconstructions, benefit from longer periods (e.g. 3 weeks) of VAC therapy to control symptoms. This can, for example, reduce exudate and allow a period of comfort before managing the wound with conservative measures. VAC therapy may also have a palliative role providing improved quality of life for terminally ill patients with pressure ulcers.


 Summary of key studies of VAC therapy in pressure ulcers 


Planning treatment

In deep infected sternal wounds debridement of bone is essential before applying VAC therapy. In suspected sternal wound infection, prompt action should involve irrigation, debridement, bone biopsy, tissue cultures and antibiotic therapy. It is important to protect underlying structures using a non‐adherent interposed layer and to position the foam dressing correctly to reduce complications 16, 17.

VAC therapy can be carried out initially for 48 hours. The viability of the wound tissue and culture results will then guide the decision to continue. Further cultures should be taken at each dressing change. Daily levels of serum C‐reactive protein may also be used to guide therapy (18). In most patients 5–12 days of VAC therapy will be appropriate.

Alert: Dehisced sternal wounds are complex, involve major organs and complications can be life‐threatening. Involvement of a cardiothoracic surgeon with relevant expertise is essential. VAC therapy must be combined with appropriate use of antibiotics and other treatments.


 Summary of key (SIGN level 2) studies of VAC therapy in dehisced sternal wounds 


Note:

Some authors suggest that VAC therapy should be used with extra caution in patients with bowel anastomoses or enterotomy repairs (20); however the technique used may be important in preventing adverse events (21).

Planning treatment

Training, education and experience in using VAC therapy in the open abdomen all positively affect outcomes. The frequency of dressing changes is also important. Dressings must be changed every 48–72 hours in the absence of wound infection. However, the exact frequency is dependent on the individual patient’s circumstances, but ideally should not be less than three times a week.

Patients with existing fistulae should be referred to a specialist centre as special techniques are required when applying VAC therapy in this situation. These include excluding the fistula before applying negative pressure to the remaining wound, and covering a small fistula with the foam dressing. The choice of technique will be influenced by the type and volume of fluid present as well as the treatment goal. These methods have been reported only as case studies and have not been formally tested in clinical trials.


 Summary of key (SIGN level 2) studies of VAC therapy in open abdominal wounds 


VAC therapy can be used in the staged management of trauma wounds to:

• • 

  stabilize soft tissue

• • 

  minimize degree of secondary damage

• • 

  aid salvage of compromized tissue

• • 

  stimulate granulation tissue formation

• • 

  reduce oedema

• • 

  reduce rates of infection

• • 

  reduce wound size and complexity

• • 

  reduce complexity of the reconstructive procedure and scar formation

• • 

  reduce number and frequency of dressing changes (to optimize patient care and comfort)

Measuring impact of VAC therapy

There is no doubt that VAC therapy can have a positive impact on a patient’s quality of life (22). Table 2 identifies how VAC therapy can improve a patient’s experience of living with a wound. However, in order to justify the use of this intervention in everyday practice where resources are limited, the clinician needs to be able to present a robust economic argument for its use. This is complicated by the seemingly high acquisition costs of the system. It is suggested that clinicians need to focus on using factors other than unit costs (e.g. reduction in hospital stay, staff labour and reduction in adverse events) to measure economic benefits. This model has been used for the diabetic foot wound, where there is evidence that VAC therapy is associated with lower overall costs of care (23). Future practice needs to find ways of developing more user‐friendly condition‐specific tools for measuring quality of life and cost‐effectiveness in wound care.

Future developments

Further research is needed to increase understanding of the therapeutic effects of VAC therapy to give clinicians stronger arguments to support its use 28, 29. In particular, future trials should focus on the generation of level 1 evidence and further comparative data for specific indications. This will help to clarify the potential for VAC therapy in different wound types and to enhance clinical decision making in various population groups. For example:

• • 

  There is a small but emerging use of VAC therapy in the paediatric population. Clarification is needed on the type of foam dressing and pressure settings to be used in these patients.

• • 

  Further research is needed to establish the relationship between negative pressure and blood flow and the optimal pressure for wound healing (30).

• • 

  The economic impact of VAC therapy requires further evaluation to justify the increased cost of treatment against the overall benefit of shorter healing times.

• • 

  As new negative pressure devices are developed, there will be a need to compare the effectiveness of the V.A.C.^® Therapy system with these emerging systems.

• • 

  Where dramatic improvements in outcome have been observed using VAC therapy (e.g. open abdomen) there are clearly ethical challenges in running comparative studies using less beneficial treatments. Prospective, multicentre studies with a common protocol should be performed and are needed.

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