CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 AFRICA 49 In another study, the likelihoods of wound healing were only 22% for large ulcers and 71% for smaller ulcers with long-term compression therapy.34 In our study, none of the patients was instructed to wear compression stockings during VAC therapy. However, given that compression therapy reduces the ulcer recurrence rate, all patients in our institute were recommended to wear high-pressure (30–40 mmHg) compression stockings continuously throughout the day at the end of the treatment. Previous studies have demonstrated that venous leg ulcers affect 0.76% of males and 1.42% of females in adults aged between 65 and 95 years.4 In our study, all patients were males. Furthermore, possible risk factors for venous leg ulcers include advanced age, female gender, familial history of leg ulcers, white race, obesity, history of DVT or phlebitis, previous severe traumatic leg injury, chronic lower-limb oedema, sedentary lifestyle, and a job requiring prolonged standing.35 Although venous leg ulcers more frequently affect elderly individuals, the first diagnosis was made at the age of 40 years in 22% and at the age of 30 years in 13% of patients.21 In their study, Taylor et al.36 found advanced age and male gender to be significant predictors of poor outcomes. Similarly, in our study, the oldest case was 79 years old, in whom diabetic foot and venous leg ulcers had recurred three times within the previous 18 months. In another study, bacterial colonisation was associated with delayed wound healing in patients with venous leg ulcers, and beta-haemolytic streptococci and anaerobic bacteria were the main culprits of delayed healing.8 Consistent with these findings, beta-haemolytic streptococci were isolated in one of our patients with the longest healing time. This case was also the oldest patient, with diabetic foot ulcer. He received 21 sessions of VAC and antibiotic therapy twice daily for 15 days. Nonetheless, we consider that the aetiology of delayed wound healing is multifactorial in venous leg ulcers. A previous history of leg trauma is considered a poor prognostic factor for leg ulcers.36 In our study, one patient had a history of leg trauma and the ulceration did not respond to previous standard treatment, with the longest ulceration time (12 months). In addition, arterial pathologies were detected in 25% of venous leg ulcers.37,38 In our study, one patient with peripheral arterial insufficiency (ABI < 0.8) was excluded, to obtain more reliable results. VAC therapy is associated with an increased risk for thromboembolism and is contra-indicated in such patients.39 In our study, we also excluded two patients with a history of DVT and one patient with acute DVT. Documentation of the characteristics of the wound bed and the wound site is of utmost importance to evaluate the healing process and the treatment response. Wound assessment requires an accurate and reproducible measurement.20 It is also critical for evaluation of the response rates. In their study, Kantor et al.40 examined the relationship between planimetric wound area and simple wound measurements and found that the correlation between simple values and planimetric area was significantly decreased for wounds > 40 cm2. In our study, we used simple measurements, and the baseline ulcer area was found to be 68.2 cm2 (mean baseline length 9.2 cm, mean baseline width 8.1 cm). Additionally, wounds with < 30% healing within the four-week treatment period were classified as hard-to-heal wounds by week 12; such patients should be re-examined for accurate diagnosis and treatment.41 In our study, the mean wound surface area was measured as 29.4 cm2 at the end of the six VAC applications by week three, indicating a 42.7% reduction. The reduction velocity was the highest within the first two weeks of VAC therapy, which can be attributed to the necrotic tissue-reducing and tissue oedemareducing effects of VAC. Until week four, the mean time to reduction was slower, however, formation of the granulation tissue increased due to the new tissue formation in the wound bed induced by VAC during this period. The epithelialisation phase covering the wound surface continued in week four. In a similar study showing the efficacy of VAC therapy, a total of 60 patients with chronic leg ulcers were equally randomised to either VAC therapy or conventional wound care.42 Among the patients receiving VAC therapy, split-thickness skin grafting was performed for wound-bed preparation. In these patients, the median preparation time was reduced by 58%, and the overall complete healing time was reduced by 35.6%, compared to the conventional wound-care group. In addition, VAC therapy reduced the treatment-related cost by 28.8% and the total nursing time by 39.9%. In our study, we achieved a 42.7% reduction in ulcer size at three weeks with VAC therapy, indicating rapid wound healing. Themain limitationof this study is the use of a classical woundmeasurement technique, which might have underestimated the accurate length and width over time, depending on the change in the wound shape. Therefore, further studies should use maximum vertical length and diameter (diameter and tissue measurement) measurements for the wound surface.43 Additionally, although it is not feasible in daily clinical practice, three-dimensional images can be obtained using sophisticated systems such as stereophotogrammetry.44 Conclusion VAC therapy is an effective and safe option for the treatment of complicated and hard-to-heal wounds and venous leg ulcers. In our study, VAC therapy enhanced wound healing, reduced the bacterial bioburden and the need for antibiotic therapy, and promoted the regression of infection. Based on these study findings, we suggest that VAC therapy is an effective and suitable tool for the treatment of venous leg ulcers. References 1. Mekkes JR, Loots MAM, van der Wal AC, Bos JD. Causes, investigation and treatment of leg ulceration. Br J Dermatology 2003; 148(3): 388–401. 2. Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcer: Incidence and prevalence in the elderly. J Am Acad Dermatology 2002; 46: 381–386. 3. Callam MJ, Harper DR, Dale JJ, Brown D, Gibson BB, Prescott RJ. Lothian and for the Valley leg ulcer healing trial, Part 1: elastic versus nonelastic bandaging in the treatment of chronic leg ulceration. Phlebology 1992; 7(4): 136–141. 4. Falanga V, Margolis D, Alvarez O, Auletta M, Maggiacomo F, Altman M, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Human Skin Investigators Group. Arch of Dermatol 1998; 134: 293–300. 5. Kahn SR, ComerotaAJ, CushmanM, et al.; AmericanHeart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing. The postthrom-
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