Use of vacuum-assisted closure (VAC) therapy in treating lymphatic complications after vascular procedures: New approach for lymphoceles
Article Outline
- Abstract
- Methods
- Results
- Discussion
- Conclusion
- Author contributions
- Tables (online only).
- References
- Copyright
Objective
Lymphatic complications, such as lymphocutaneous fistula (LF) and lymphocele, are relatively uncommon after vascular procedures, but their treatment represents a serious challenge. Vacuum assisted closure (VAC) therapy has been reported to be an effective therapeutic option for LF, but the effectiveness of VAC therapy for lymphoceles is unclear.
Methods
For LF, we apply the VAC directly to the skin defect after extending it to achieve a clean wound of at least one inch in length. To treat lymphocele, we convert the lymphocele to a LF in a sterile fashion by making a one inch incision in the overlying skin and applying the VAC. The setting was a community teaching hospital. We used 10 patients that we treated with VAC therapy for LF (n = 4) and lymphoceles (n = 6).
Results
Duration of in-patient stay, duration of in-patient VAC treatment, duration of out-patient VAC treatment, total duration of VAC treatment. The median duration of in-patient stay was 4 (range, 0-18) days, the median duration of in-patient VAC treatment was 1 (range, 0-5) days, the median duration of out-patient VAC treatment was 16 (range, 7-28) days), and the median total duration of VAC therapy was 18 (range, 13-29) days. Successful wound healing was achieved in all patients with no recurrence after VAC removal. VAC therapy for treatment of both LFs and lymphoceles resulted in early control of drainage, rapid wound closure, and short hospital stays.
Conclusion
Our results suggest that VAC therapy is a convenient and effective therapeutic option for both LFs and lymphoceles.
Lymphatic complications, such as lymphocutaneous fistula (LF) and lymphocele, are relatively uncommon after vascular procedures, but they represent a serious challenge for surgeons. A lymphocele is a cystic collection of lymphatic fluid from a disrupted lymphatic channel that forms a pocket in the soft tissue of the healing wound. Continued fluid accumulation in fresh wounds may cause wound disruption and continued lymphatic drainage, which constitute a LF.1 Lymphatic complications most commonly occur in the groin after vascular exposure, but they can occur elsewhere in the body, including the neck. Significant risk factors are previous groin dissection, aortobifemoral reconstruction, and presence of a foreign body.2, 3, 4, 5, 6, 7 These complications represent significant potential morbidity and mortality.6
Patients with lymphatic complications have increased length of hospital stay, ranging from 22 to 36 days, and significantly increased risk of wound infection, reportedly up to 18%.3, 5, 6 In the case of an underlying prosthetic graft, lymphatic complications can result in possible graft infection with the need for graft removal. This represents a significant health care utilization burden and source of morbidity.
Several therapeutic options have been described in the literature for treatment of both LF and lymphocele (Table I, online only). Treatments for LF include conservative dressing changes,8, 9 leg elevation,10 pressure dressings, drain placement, local irradiation,10 surgical ligation of the leaking lymphatic channel,7, 11, 12 and in the case of an infected graft, muscle flap coverage after graft removal.7, 13, 14 These treatment modalities are associated with variable degrees of success. Existing literature supports early identification through surgical exploration and lymphatic ligation,7, 11, 12 but this exposes the patient to an additional invasive procedure that increases cost and length of hospital stay.
Available therapeutic options for lymphoceles include conservative out-patient observation, percutaneous drainage, sclerotherapy with bleomycin, doxycyclin or ethanol, local irradiation, videoscopic argon beam coagulation, surgical exploration with lymphatic ligation, and muscle flap coverage (Table I, online only).2, 15, 16, 17, 18, 19 There is no consensus in the literature regarding the preferred treatment of lymphoceles.
Vacuum-assisted closure (VAC) was reported as a novel therapeutic option for lymphocutaneous fistula in two small case series by Abai et al and Greer et al (total 5 patients).1, 20 We are not aware of any previously published report on the use of VAC for lymphoceles.
In this study, we describe our experience with VAC therapy over the last 4 years in treating LFs and lymphoceles after various vascular procedures.
Methods
We retrospectively reviewed the charts of 10 patients (five female) who developed lymphatic complications after surgery and were treated with VAC therapy (Kinetic Concepts, San Antonio, Tex at Good Samaritan Hospital in Cincinnati, Ohio) between July 2005 and October 2007. The following demographic and medical background variables were recorded for all patients: age, gender, body mass index (BMI), presence of risk factors (ie, diabetes, hypertension), previous disruption of lymphatics (eg, previous surgery, radiation), type of original surgery, presence of graft, time from surgery to diagnosis of lymphatic complication, site and type of lymphatic complication, time from diagnosis of lymphatic complication to VAC treatment, and total duration of VAC therapy. Post-VAC therapy follow-up was also recorded. This study was granted full approval of the Institutional Review Board. All data analysis was performed using SPSS 15.0 (SPSS Corporation, Chicago, Ill).
The diagnosis of LF is made clinically based on clear fluid drainage from the incision. We start with a conservative treatment approach of heavy dressings and bed rest. If the patient is still saturating multiple heavy dressings and drainage is not decreasing after 24-48 hours, we apply VAC. We attempted exploration and identification of a leaking lymphatic channel with and without blue dye in 3 patients (2 lymphoceles, 1 LF), but all 3 of these patients experienced recurrence.
The development of lymphoceles after vascular procedures is not uncommon in our institution due to our oblique approach to expose the femoral artery. We use clinical judgment, percutaneous aspiration (clear serous fluid), and sometimes color Doppler sonography scan to diagnose lymphocele. If a patient has a graft, a CT scan should be obtained to evaluate the relation between the fluid collection and the graft. In general, we do not advise application of VAC directly on grafts. Most diagnoses of lymphoceles are made during the first postoperative office visit – typically patients have nonpulsatile groin swelling with no evidence of overlying infection. We initially attempt to treat symptomatic lymphoceles with percutaneous aspirations in the office to relieve patient symptoms. If a patient has had symptomatic recurrence after multiple aspirations (average 4-5 times), we apply VAC by converting the lymphocele to LF.
We use the regular black sponge polyurethane (PU) foam dressing (GranuFoam Dressing, KCI Licensing, Inc., San Antonio, Tex) and continuous suction at 125 mm Hg. We change the dressings three times a week and see patients in the office every 2 weeks, unless a complication requires urgent attention. We receive a report from the visiting nurse after every dressing change. The decision to stop the VAC is based on no drainage from the wound for 2-3 days and good wound healing in terms of granulation tissue formation. We then instruct patients to initiate simple wet to dry dressing until the wound completely heals. None of our patients required skin graft because the skin defect after removal of VAC is small enough to allow healing with secondary intention.
Results
Demographic and descriptive information for the cases are presented in Table II (online only). The mean age and BMI of patients in the sample was 65 +/− 16 years and 24 +/− 4 kg/m2, respectively. Six patients had comorbid diabetes mellitus; 7 patients had comorbid hypertension. Nine patients in the sample had groin lymphatic complications after surgery and 1 patient had a neck lymphatic complication. Four patients had a previous disruption of their groin lymphatics. Four grafts were involved in the surgical field; none of these grafts were exposed or in direct contact with VAC. Results related to duration of time from surgery to wound healing for all cases and across type of lymphatic complication are provided in Table III. The median duration between diagnosis of lymphatic complications and VAC application was 12 days; the shortest time from diagnosis to VAC application was 1 day. The median duration of in-patient stay for treatment of lymphatic complications was 4 days; patients used the VAC dressing during their in-patient stay for a median of 1 day. The average total duration of VAC treatment was 18 +/− 5 days. A success rate in achieving complete resolution of lymphatic complications with VAC was 100%, as no clinically detectable recurrences have been reported after an average follow-up of 17 +/− 12 months.
Table III. Results
| Time period (days) | All median (range) | Lymphocutaneous fistula median (range) | Lymphocele median (range) |
|---|---|---|---|
| Surgery to diagnosis of complication | 22 (3-119) | 7(3-119) | 26(9-43) |
| Diagnosis of complication to start of VAC treatment | 12(1-480) | 3(1-18) | 28(1-480) |
| Duration of in-patient stay | 4(0-18) | 5(3-18) | 1(0-5) |
| Duration of in-patient VAC treatment | 1(0-5) | 2(1-5) | 1(0-2) |
| Duration of out-patient VAC treatment | 16(7-28) | 15(7-28) | 18(11-21) |
| Total duration of VAC treatment | 18(13-29) | 17(12-29) | 18(13-22) |
| Duration of follow-upa | 12(4-32) | 29(4-32) | 11(5-29) |
aTime is in months. |
Discussion
Lymphatic complications after infrainguinal incision and dissection are usually attributed to destruction during the dissection without attention to detailed ligation of small lymphatics. Based on the anatomy of the lymphatic vessels in this region, a vertical dissection minimizes disruption and decreases subsequent formation of a lymphocele or LF. A vertical groin incision is associated with less postoperative lymphatic complications compared to an oblique incision.21, 22, 23 However, oblique incisions in the groin as an access for femoral artery during endovascular repair of abdominal aortic aneurysm (AAA) are associated with less infection, especially in morbidly obese patients.22, 24, 25 In addition to the direction of groin incision, some surgeons advocate the use of fibrin glue to help prevent lymphatic complications.23
Despite all efforts to prevent lymphatic complications, the overall reported incidence of groin lymphatic complications after vascular procedures ranges from 1.2 to 5.1%.2, 3, 4, 5, 6 These complications are a major challenge for the surgeon, especially when a prosthetic material is involved in the underlying wound. There is no consensus on optimal treatment for lymphatic complications. The application of surgical treatments suggested in the literature may increase the cost and duration of hospital stays and exposes patients to an additional invasive procedure.
Since its introduction by Argenta and coworkers in 1995 as a wound treatment modality, VAC treatment has proved to be one of the most effective methods in the management of all types of wounds.26, 27 The United States Food & Drug Administration (US FDA) granted approval for wound treatment by VAC device in 1995. The first clinical data in the English language on its use in a variety of chronic wound conditions was published in 1997.26
Initial studies on animals showed that VAC increased granulation tissue formation by 103 ± 35% per day compared to wet to dry dressing.28 This is caused by increasing blood flow to the wound, decreasing the interstitial fluid and edema, removal of inflammatory mediators that are detrimental to wound healing, and finally by increasing local cellular response in the wound. VAC also has been shown to decrease the bacterial counts in grossly infected wounds.28
Demaria et al reported VAC to be a useful method to treat groin infection after emergency vascular procedures.29 Two years later, Dosluoglu et al reported the usefulness of VAC in preserving infected exposed vascular grafts without muscle flap in 4 high-risk surgical patients.30 Pinocy et al also used VAC to treat periprosthetic soft tissue infection of the groin with good results.31
Greer et al reported their experience with VAC treatment for LF in the groin in a small case series consisting of 2 patients.20 The authors reported good results and concluded that VAC therapy was a promising treatment option. In another small case series, Abai et al reported good results of negative pressure wound therapy in the treatment of groin LF in three cases at their institution.1 The mean time of cessation of lymphatic drainage in their case series was 14 days.
To the best of our knowledge, the present study is the first to report the use of VAC therapy following conversion of recurrent lymphocele to LF in sterile fashion. Although we are not suggesting that VAC should be the primary therapy for patients with lymphatic complications after vascular procedures, and we are not stating that every lymphocele should be treated with VAC, these results suggest that VAC is an effective alternative treatment option for recurrent symptomatic lymphocele or LF that has failed out-patient conservative management. Moreover, VAC is readily available, easy to use, and has good patient satisfaction, especially with small portable home devices.
Conclusion
In this case series, we described the use of VAC to treat nine lymphatic complications after variable vascular procedures with 100% success rate and no recurrence. We had four grafts involved and we were able to save them with no graft infection. VAC is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides early control of drainage and rapid wound closure.
Author contributions
Tables (online only)
Table I, online only. Therapeutic options for lymphatic complications
| Study/treatment | N | LF/lymphocele | Previous intervention | Duration from treatment to resolution (days) | Length of hospital stay (days) | Complications | Recurrence rate | Follow-up (months) |
|---|---|---|---|---|---|---|---|---|
| McShannic et al 19978a | 32 | 29/3 | None | 5 | 42 | |||
| Exploration and ligation | 24 | —x | 2 | 11 | — | 0/24(0%) | ||
| Conservative management | 8 | — | 38 | 26 | — | 0/8(0%) | ||
| Procellini et al 20029 | 23 | — | None | 12 | ||||
| Out-patient limited ambulation; limb elevation; pressure dressings | 0/23 | 21 | 11 days (in patients diagnosed while in hospital) | 1 infection | 0/23(0%) | |||
| Roberts et al 19932 | 8 | 3/5 | — | — | 3to51 | |||
| Conservative treatment (bed rest; recurrent percutaneous aspirations; pressure dressing) | 8 | 3/5 | — | 8/8(100%) | ||||
| Exploration, identification and ligation of leaking lymphatics with lymphocele excision | 8 | 3/5 | Failed conservative management | — | ||||
| Tyndall et al 19943b | 41 | 28/13 | None | 41 | ||||
| Conservative treatment (bed rest; IV antibiotics; aggressive local wound care) | 29 | 18/11 | 24 | 25 | 5 infections, one in graft resulting in limb amputations | 0/29(0%) | ||
| Exploration and ligation with meticulous closure | 12 | 10/2 | 9 | 17 | No infections; 1 pulmonary embolism | 2/12(17%) | ||
| Schwartz et al 199512 | 17 | 8/9 | ||||||
| Conservative management; bed rest; elevation; pressure dressing; oral antibiotics | 17 | 8/9 | None | 74 | 19 | 5/17 | 10/17(59%) | 14 |
| Operative (exploration and ligation with dye) | 10 | 4/6 | Failed conservative management | 18 | 3 | 0 | 1/10(10%) | 26 |
| Shermak et al 20057 | 34 | — | ||||||
| Conservative out-patient management, bed rest, aspiration, doxycyclin injection, incision and drainage | 14 | — | — | — | — | — | 14/14(100%) | — |
| Exploration, identification, and ligation of leaking lymphatic with wall excision | 15 | — | 7 patients failed less invasive treatment | — | 5 | — | 4/15(27%) | — |
| Muscle flap coverage | 22 | — | 10 patients failed operative and nonoperative treatment | — | 9 | 4/22 | — | 18 |
| Stadelmann et al 200113 | 19 | — | ||||||
| Exploration, identification, and ligation of leaking lymphatic channel using isosulfan blue dye under general anesthesia; bed rest for 5 days post op; no excision of lymphocele wall. Three patients needed muscle flap coverage. | 4/15 | 6 patients failed previous operative intervention, 3 patients failed conservative management | — | At least 5 days for bed rest then activity advanced, pressure dressings for 2 weeks, sutures removed at 3 weeks | 1 groin hematoma; 1 abscess at blue dye injection site; 1groin abscess blue hue at injection site | 0/15(0%) | 18 | |
| Kwaan et al 197911 | 12 | 12/0 | None | |||||
| Conservative management; pressure dressing, systemic antibiotics; immobilization; application of povidone-iodine | 7 | — | 28-42 | 28 | 3 infections, one with graft involvement resulting in amputations | 1/7(with persistent drainage) | — | |
| Exploration, identification and ligation of leaking lymphatic channel (with and without dye) | 5 | — | — | 11 | None | 0% | — |
aNumber of references in this paper. |
bOperative intervention for lymphoceles did not reduce hospital stay or infectious wound complications. Repetitive aspirations also did not affect rapidity of resolution or increase infectious complications. |
Table II, online only. Cases
| Patient | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
|---|---|---|---|---|---|---|---|---|---|---|
| Age | 73 | 85 | 69 | 63 | 36 | 51 | 59 | 47 | 80 | 82 |
| Gender | Male | Female | Male | Male | Female | Female | Male | Female | Male | Female |
| BMI (Kg/m2) | 26.0 | 25.9 | 22.8 | 26.6 | 25.4 | 17.8 | 27.1 | 31.0 | 22.0 | 20.0 |
| DM | Y | Y | Y | Y | N | Y | Y | N | N | N |
| HTN | N | Y | Y | Y | N | Y | Y | N | Y | Y |
| Previous disruption to lymphatics | APR for rectal Ca, with history of radiation | R hip replacement | N | N | N | N | N | N | FA cutdown for cannulation for robotic assisted MV repair | R femoral to popliteal bypass graft |
| Type of surgery | FA cutdown for EVAR | R FA cutdown for EVAR | FA cutdown for retroperitoneal Aorto-Bifem | FA cutdown for Aorto-Bifem | Ligation and division of GSV at sapheno-femoral junction | L carotid to subclavian bypass graft | FA cutdown for cannulation during robotic assisted MV repair | FA cutdown for cannulation during robotic assisted MV repair | Removal of Goretex suture for recurrent L groin infection | R common FA angioplasty; thrombectomy of femoral to popliteal graft |
| Graft | N | N | Y | Y | N | Y | N | N | N | Y |
| Surgery to diagnosis (days) | 22 | 119 | 7 | 6 | 42 | 22 | 30 | 43 | 9 | 3 |
| Site of lymphatic complication | L Groin | R Groin | R Groin | R Groin | R Groin | L Neck | R Groin | R Groin | L Groin | R Groin |
| Type of lymphatic complication | Lymphocele | LF | LF | LF | Lymphocele | Lymphocele | Lymphocele | Lymphocele | Lymphocele | LF |
| In-patient treatment for lymphatic complications | 5 | 3 | 18 | 4 | 0 | 5 | 1 | 0 | 0 | 5 |
| Treatment before VAC | Percutaneous aspiration; bed rest; exploration, resection, identification, and ligation; Fibrin glue application | Heavy dressing | Dressing change; exploration, identification, and ligation | Dressing change; bed rest | Recurrent percutaneous aspirations; excision of lymphocele and primary closure | Observation; oral antibiotics | Recurrent percutaneous aspirations | Recurrent percutaneous aspirations | Recurrent percutaneous aspirations; pressure dressing | Heavy pressure dressing |
| Diagnosis to VAC (days) | 480 | 1 | 5 | 1 | 122 | 1 | 39 | 7 | 16 | 18 |
| Duration of VAC (days) | 22 | 14 | 13 | 19 | 20 | 13 | 22 | 16 | 16 | 29 |
| Follow-up (months) | 29 | 30 | 32 | 27 | 10 | 13 | 11 | 5 | 5 | 4 |
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Competition of interest: none.
Additional material for this article may be found online at www.jvascsurg.org.
CME article
PII: S0741-5214(08)01206-8
doi:10.1016/j.jvs.2008.07.059
© 2008 Published by Elsevier Inc.