CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 48 AFRICA VAC of 12.1 days (range 5–21) (mean number of VAC sessions 4.2). None of the patients needed antibiotic therapy until the VAC therapy was completed. The mean duration of leg ulcers was 7.2 months. Of all the ulcers, recurrence was observed in one case twice and in another three times. Five of the ulcers were newly diagnosed. Discussion In this study, we examined the effect of VAC therapy on venous stasis wound healing in patients with chronic venous leg ulcers. Our study results showed that VAC therapy was an effective and rapid method of treating venous leg ulcers and had an accelerated wound-healing effect. Negative pressure was first used for wound healing in 1993 by Fleischmann et al.23 Approximately 70% of chronic leg ulcers are caused by venous diseases. The underlying aetiology of venous insufficiency is venous hypertension.24 However, its pathogenesis, ranging from valve regurgitation to ulceration, remains unclear. Clinical symptoms of venous insufficiency include oedema, lipodermatosclerosis, hyperpigmentation, hyperkeratosis and atrophie blanche (white atrophy).25 At a microvascular level, microlymphangiopathy, dilatations of the larger lymph vessels, dilatation and extension of capillaries, occlusion of the capillaries by microthrombi or white cells, decline in the number of functional capillaries, increase in the capillary passage, leakage of plasma proteins and red blood cells into the interstitium and accumulation of iron into the interstitium and siderophages, accumulation of fibrins, and inward growth of the fibroblasts along the fibrin fibres can occur.24 Most studies consider that haemodynamic alterations occurring at the microvascular level explicitly indicate venous ulceration.26,27 In our study, chronic venous insufficiency was the main aetiology of all ulcers. Clinical studies have reported low rates of wound healing with standard treatment of venous leg ulcers.27 General medical management is the cornerstone of standard treatment. This is followed by clinical examination and the maintenance of adequate oxygenation and perfusion. An intervention is planned, if required. For the underlying pathology, venous surgery, endovenous laser ablation, radiofrequency ablation, sclerotherapy, or subfascial endoscopic perforator surgery may be applied. In certain cases, compression therapy is useful with local wound care. In a retrospective, multicentre study, 68 patients with venous leg ulcers were treated with serial debridement, and complete wound closure was achieved in 32 (47%) patients by week 12.28 In the remaining centres, 298 patients were treated and complete healing was achieved in 88 (30%) patients by week 12. In our study, none of the patients received surgical debridement. The mean reduction rate of ulcers was 46.4% by week four, indicating a greater reduction in a shorter time compared to the data in the literature. The most frequently isolated micro-organisms in infected venous leg ulcers are P aeruginosa, S aureus and haemolytic streptococci.9 Surgical debridement followed by wound dressing with topical antibiotics and antimicrobials is recommended for the management of bacterial bioburden. In a Cochrane Review of 25 published studies, there was a statistically significant result in favour of cadexomer iodine compared to standard care in the frequency of complete healing at six weeks.29 In addition, there was some evidence to show a reduction in the bacterial bioburden in patients with infected venous leg ulcers. In another study, increased blood flow reduced interstitial tissue oedema and eliminated harmful bacterial enzymes, promoting the wound-healing process and quality.30 In our study, all ulcers were infected at baseline. Consistent with the literature, MDR P aeruginosa and MRSA were isolated in three and four patients, respectively. In addition, current consensus guidelines recommend antibiotic treatment for a minimum of two weeks unless persistent evidence of wound infection is present.31 In our study, the mean duration of antibiotic therapy was 4.5 days (mean: three to 12 days) for the first six applications. Quantitative wound culture results became negative after a mean VAC duration of 12.1 days and none of the patients needed antibiotic therapy until the end of the VAC therapy. The wound culture became negative five days after the initiation of VAC therapy (two sessions) in three patients. In our study population, antibiotics reduced the bacterial colonisation and bioburden in the wound site and removed the need for surgical debridement. Additionally, no local antiseptic agents were used for dressing changes. During the third dressing change with a sterile adhesive bandage, the new formation of granulation tissue and surroundings was evident. No bacterial growth was detected in subsequent VAC applications until the end of the therapy. Our application seems to be consistent with the literature, suggesting the use of antibiotics for a minimum of two weeks. Although the wounds were closed with dressings, VAC therapy was completed without the need for surgical debridement and further antibiotic therapy in all cases. In a study analysing 679 swabs of 285 patients with venous leg ulcers, 76.1% gram-positive and 58.2% gram-negative bacteria were isolated.12 In our study, gram-negative bacteria were found to be associated with more pain and were isolated in eight ulcers. These patients reported a higher pain severity, consistent with the literature. High-pressure (30–40 mmHg) compression stockings are recommended for venous leg ulcers. In a Cochrane Review of 19 databases and two randomised, controlled trials, the authors investigated the effect of compression stockings in preventing the recurrence of venous ulcers.32 Half of the patients were unable to wear compression stockings on their own, with a 30 to 65% non-compliance rate. In addition, compression therapy was found to be more effective than no compression therapy, high-pressure compression stockings were more effective than low-pressure stockings, and multi-layer compression bandages were more effective than single-layer bandages. In over 400 patients with ulcer healing, the continuous use of compression stockings reduced the recurrence rate after three to five years of follow up. In a randomised, controlled study, the healing and recurrence rates after treatment with compression with or without surgery were evaluated in patients with leg ulcers.33 Venous duplex imaging of ulcerated or recently healed legs in 500 patients from three centres was performed, and the recurrence rate was found to be significantly lower at four years in the combinationtherapy group than in the compression-alone group (24 vs 52%, respectively). However, up to 20% of leg ulcers showed no healing by 50 weeks after compression therapy.
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