NPWT in Complex Surgical Management of Combat Vascular Injuries of the Limbs: Fundamentals of Safe Application and Clinical Experience

  • Iurii Iu. Sivash National Military Medical Clinical Center “Main Military Clinical Hospital”, Kyiv, Ukraine; Bogomolets National Medical University, Kyiv, Ukraine https://orcid.org/0000-0002-7956-6378
  • Boris M. Koval National Military Medical Clinical Center “Main Military Clinical Hospital”, Kyiv, Ukraine; Bogomolets National Medical University, Kyiv, Ukraine https://orcid.org/0000-0003-0166-8603
DOI: https://doi.org/10.63181/ujcvs.2025.33(4).136-146
Keywords: extremity major vascular injuries, negative pressure wound therapy, NPWT, wound infection, hemorrhage, war in Ukraine

Abstract

Introduction. Combat vascular injury of the limbs represents one of the most complex categories of trauma. Such injuries are rarely isolated and are often accompanied by extensive soft-tissue defects and microbial contamination, leading to severe complications such as thrombosis and erosive bleeding. Their treatment remains challenging, prolonged, and frequently results in limb loss. Negative pressure wound therapy (NPWT) has proven to be an effective method for managing complex gunshot wounds in combat conditions; however, evidence on its safe application in vascular limb trauma remains limited.

Aim. To analyze theoretical and practical aspects of the safe use of NPWT in combat-related injuries of major limb vessels and to determine the indications, contraindications, and optimal technical parameters for its application.

Materials and Methods. A comparative analysis of published data and clinical observations was performed, including cases of combat vascular injury of the lower limbs with associated soft-tissue defects where NPWT was used as part of staged surgical management.

Results. Key indications, contraindications, and principles for safe NPWT use in vascular surgery were defined. The application of a two-layer dressing with a protective interface and continuous negative pressure of 70–80 mmHg ensured procedural safety in vascular reconstruction zones, promoted rapid wound cleansing and granulation, and enabled successful delayed closure using skin-grafting techniques.

Conclusions. NPWT is an effective adjunct in the complex surgical management of combat vascular limb injuries combined with soft-tissue loss. Safe application requires reliable protection of the vascular anastomosis, maintenance of continuous negative pressure, and individualized risk assessment. Further research should focus on developing unified clinical protocols for NPWT in combat vascular trauma, including reliable vessel protection methods and prevention of procedure-related complications.

References

  1. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011 Jun;253(6):1184–9. https://doi.org/10.1097/sla.0b013e31820752e3
  2. Chandler H, MacLeod K, Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, et al. Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003–2014. Injury. 2017 Jul;48(7):1439–43. https://doi.org/10.1016/j.injury.2017.05.022
  3. Ran Y, Mitchnik I, Gendler S, Avital G, Radomislensky I, Bodas M, et al. Isolated limb fractures – the underestimated injury in the Israeli Defence Forces (IDF). Injury. 2023 Feb;54(2):490–6. https://doi.org/10.1016/j.injury.2022.11.014
  4. Klausner MJ, McKay JT, Bebarta VS, Naylor JF, Fisher AD, Isherwood KD, et al. Warfighter personal protective equipment and combat wounds. Med J Fort Sam Houst Tex. 2021;PB 8-21-04/05/06:72–7.
  5. Brown KV, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC. Complications of extremity vascular injuries in conflict. J Trauma. 2009 Apr;66(4 Suppl):S145–9. https://doi.org/10.1097/TA.0b013e31819cdd82
  6. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg. 2007 Apr;204(4):625–32. https://doi.org/10.1016/j.jamcollsurg.2007.01.040
  7. Hinck D, Franke A, Gatzka F. Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries. Mil Med. 2010 Mar;175(3):173–81. https://doi.org/10.7205/MILMED-D-09-00075
  8. Maurya S, Bhandari PS. Negative pressure wound therapy in the management of combat wounds: a critical review. Adv Wound Care. 2016 Sep;5(9):379–89. https://doi.org/10.1089/wound.2014.0624
  9. Zarutskyi Y, Aslanyan S, Kravchenko K, Vovk M, Honcharuk V. The use of negative pressure vacuum therapy in the treatment of soft tissue defects in thoracic injury. Nor J Dev Int Sci. 2021;1(59):17–23. https://doi.org/10.24412/3453-9875-2021-59-1-17-23
  10. Joint trauma system clinical practice guideline. War wounds: debridement and irrigation (CPG ID:31). 2021 Sep 21. Available from: https://jts.health.mil/assets/docs/cpgs/War_Wounds_Debridement_and_Irrigation_27_Sep_2021_ID31.pdf
  11. Zarutskyi Y, Aslanyan S, Plis I, Kompaniiets A, Goncharuk V. Application of NPWT in the surgical treatment of wounds and injuries of various locations: case series. Negat Press Ther J. 2018 Sep;5(3):10–3. https://doi.org/10.18487/npwtj.v5i3.44
  12. Strilka RJ, Gavitt BJ, Proctor M, Klein AA, Anderson MO. Critical care air transport clinical practice guideline (CCATT CPG): negative pressure wound therapy during critical care air transport. 2025 Feb 26. Available from: https://jts.health.mil/assets/docs/cpgs/NPWT_CCATT_26_Feb_2025.pdf
  13. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg. 2004 Oct;114(5):1086–96. https://doi.org/10.1097/01.prs.0000135330.51408.97
  14. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment. Ann Plast Surg. 1997 Jun;38(6):553–62. https://doi.org/10.1097/00000637-199706000-00001
  15. Lambert KV, Hayes P, McCarthy M. Vacuum assisted closure: a review of development and current applications. Eur J Vasc Endovasc Surg. 2005 Mar;29(3):219–26. https://doi.org/10.1016/j.ejvs.2004.12.017
  16. Stannard JP, Volgas DA, Stewart R, McGwin G, Alonso JE. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma. 2009 Sep;23(8):552–7. https://doi.org/10.1097/BOT.0b013e3181a2e2b6
  17. Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014 Jul;51(7):301–31. https://doi.org/10.1067/j.cpsurg.2014.04.001
  18. Téot L, Apelqvist J, Fagerdahl A, Willy C. Negative pressure wound therapy: an update for clinicians and outpatient caregivers. J Wound Manag. 2024;25(2):1–56. https://doi.org/10.35279/jowm2024.25.02.sup01
  19. Білий В., Заруцький Я., Собко І., Гуменюк К., Король С., Асланян С. Вакуумні пов’язки в лікуванні ран м’яких тканин при бойовій хірургічній травмі [Vacuum dressings in the treatment of soft tissue wounds in combat surgical trauma] [Internet]. Київ: Людмила [Liudmyla]; 2023 [cited 2025 May 22]. 39 p. Available from: https://emed.library.gov.ua/medytsyna-voiennoho-i-povoiennoho-chasu/vakuumni-poviazky-v-likuvanni-ran-miakykh-tkanyn-pry-boyoviy-khirurhichniy-travmi-2/
  20. Krug E, Berg L, Lee C, Hudson D, Birke-Sorensen H, Depoorter M, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus. Injury. 2011 Feb;42 Suppl 1:S1–12. https://doi.org/10.1016/S0020-1383(11)00041-6
  21. Cuomo R, Grimaldi L, Nisi G, Zerini I, Giardino FR, Brandi C. Ultraportable devices for negative pressure wound therapy: first comparative analysis. J Investig Surg. 2019;34(3):335–43. https://doi.org/10.1080/08941939.2019.1616009
  22. Cuomo R, Giardino FR, Nisi G, et al. Fat graft for reducing pain in chronic wounds. Wound Repair Regen. 2020;28:780–8. https://doi.org/10.1111/wrr.12846
  23. Normandin S, Safran T, Winocour S, et al. Negative pressure wound therapy: mechanism of action and clinical applications. Semin Plast Surg. 2021;35(3):164–70. https://doi.org/10.1055/s-0041-1731792
  24. Brown KV, Murray CK, Clasper JC. Infectious complications of combat-related mangled extremity injuries in the British military. J Trauma. 2010 Jul;69 Suppl 1:S109–15. https://doi.org/10.1097/TA.0b013e3181e4b33d
  25. Seth I, Gibson D, Lim B, Cevik J, Bulloch G, Xie Y, Marcaccini G, Rozen WM, Cuomo R. Advancements, applications, and safety of negative pressure wound therapy: a comprehensive review of its impact on wound outcomes. Plast Aesthet Res. 2024;11:29. https://doi.org/10.20517/2347-9264.2024.05
  26. Saunders C, Nherera LM, Horner A, Trueman P. Single-use negative-pressure wound therapy versus conventional dressings for closed surgical incisions: systematic literature review and meta-analysis. BJS Open. 2021;5(1):zraa003. https://doi.org/10.1093/bjsopen/zraa003
  27. James K, Glasswell A, Costa B. Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: systematic literature review and meta-analysis. Am J Surg. 2024;228:70–7. https://doi.org/10.1016/j.amjsurg.2023.10.031
  28. Grant-Freemantle MC, Ryan ÉJ, Flynn SO, et al. The effectiveness of negative pressure wound therapy versus conventional dressing in the treatment of open fractures: a systematic review and meta-analysis. J Orthop Trauma. 2020;34(5):223–30. https://doi.org/10.1097/BOT.0000000000001750
  29. Department of the Army, Office of The Surgeon General. Soft-tissue injuries. In: Emergency war surgery: third United States revision. 3rd ed. Washington (DC): Walter Reed Army Medical Center, Borden Institute; 2004. p.102–3.
  30. Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma. 2006 Nov;61(5):1207–11. https://doi.org/10.1097/01.ta.0000241150.15342.da
  31. Peck MA, Clouse WD, Cox MW, Bowser AN, Eliason JL, Jenkins DH, et al. The complete management of extremity vascular injury: a wartime report from the 332nd Expeditionary Medical Group. J Vasc Surg. 2007 Jun;45(6):1197–204. https://doi.org/10.1016/j.jvs.2007.02.003
  32. Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 2007 Jul;21(6):394–9. https://doi.org/10.1097/BOT.0b013e318070c028
  33. Machen S. Management of traumatic war wounds using vacuum-assisted closure dressings in an austere environment. US Army Med Dep J. 2007;17–23.
  34. Mansoor J, Ellahi I, Junaid Z, Habib A, Ilyas U. Clinical evaluation of improvised gauze-based negative pressure wound therapy in military wounds. Int Wound J. 2015 Oct;12(5):559–63. https://doi.org/10.1111/iwj.12164
  35. Maurya S, Srinath N, Bhandari PS. Negative pressure wound therapy in the management of mine blast injuries of lower limbs: lessons learnt at a tertiary care center. Med J Armed Forces India. 2017 Oct;73(4):321–7. https://doi.org/10.1016/j.mjafi.2016.06.002
  36. Back DA, Scheuermann-Poley C, Willy C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions: when, where and how to use—what does the evidence show? Int Wound J. 2013;10 Suppl 1:32–42. https://doi.org/10.1111/iwj.12183
  37. Silverman RP. Negative pressure wound therapy with instillation and dwell time: mechanisms of action literature review. Eplasty. 2023 Aug;23. Available from: https://www.hmpgloballearningnetwork.com/site/eplasty/review/negative-pressure-wound-therapy-instillation-and-dwell-time-mechanisms-action
  38. Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections. Eur J Vasc Endovasc Surg. 2020 Mar;59(3):339–84. https://doi.org/10.1016/j.ejvs.2019.10.016
  39. Quacinella MA, Yong TM, Obremskey WT, Stinner DJ. Negative pressure wound therapy: where are we in 2022? OTA Int. 2023 Jul;6(4 Suppl):e247. https://doi.org/10.1097/OI9.0000000000000247
  40. Mayer D, Hasse B, Koelliker J, Enzler M. Long-term results of vascular graft and artery preserving treatment with negative pressure wound therapy in Szilagyi grade III infections justify a paradigm shift. Ann Surg. 2011 Nov;254(5):754–60. https://doi.org/10.1097/SLA.0b013e3182359a9c
  41. Monsen C, Acosta S, Mani K, Wann-Hansson C. A randomised study of NPWT closure versus alginate dressings in peri-vascular groin infections: quality of life, pain and cost. J Wound Care. 2015 Jun;24(6):252–6. https://doi.org/10.12968/jowc.2015.24.6.252
  42. Fang R, Dorlac WC, Flaherty SF, Tuman C, Cain SM, Popey TL, et al. Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties. J Trauma. 2010 Jul;69 Suppl 1:S140–5. https://doi.org/10.1097/TA.0b013e3181e452a2
  43. Geiger S, McCormick F, Chou R, Wandel AG. War wounds: lessons learned from Operation Iraqi Freedom. Plast Reconstr Surg. 2008 Jul;122(1):146–53. https://doi:10.1097/PRS.0b013e3181773d19
  44. Matatov T, Reddy KN, Doucet LD, Zhao CX, Zhang WW. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. J Vasc Surg. 2013 Mar;57(3):791–5. https://doi.org/10.1016/j.jvs.2012.09.037
  45. Lang W, Horch RE. Distal extremity reconstruction for limb salvage in diabetic foot ulcers with pedal bypass, flap plasty and vacuum therapy. Zentralbl Chir. 2006 Apr;131 Suppl 1:S146–50. https://doi.org/10.1055/s-2006-921472
  46. Kotsis T, Lioupis C. Use of vacuum assisted closure in vascular graft infection confined to the groin. Acta Chir Belg. 2007;107(1):37–44. https://doi.org/10.1080/00015458.2007.11680008
  47. Dosluoglu HH, Schimpf DK, Schultz R, Cherr GS. Preservation of infected and exposed vascular grafts using vacuum assisted closure without muscle flap coverage. J Vasc Surg. 2005 Nov;42(5):989–92. https://doi.org/10.1016/j.jvs.2005.07.006
  48. Berger P, de Bie D, Moll FL, de Borst GJ. Negative pressure wound therapy on exposed prosthetic vascular grafts in the groin. J Vasc Surg. 2012 Sep;56(3):714–20. https://doi.org/10.1016/j.jvs.2012.02.007
  49. Li Z, Yu A. Complications of negative pressure wound therapy: a mini review. Wound Repair Regen. 2014;22:457–61. https://doi.org/10.1111/wrr.12190
  50. Forsberg JA, Pepek JM, Wagner S, Wilson K, Flint J, Andersen RC, et al. Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg Am. 2009 May;91(5):1084–91. https://doi.org/10.2106/JBJS.H.00792
  51. Apelqvist J, Willy C, Fagerdahl AM, et al. EWMA Document: Negative Pressure Wound Therapy. J Wound Care. 2017;26(Sup3):S1–154. https://doi.org/10.12968/jowc.2017.26.Sup3.S1
  52. Sumpio BE, Allie DE, Horvath KA, Marston WA, Meites HL, Mills JL, et al. Role of negative pressure wound therapy in treating peripheral vascular graft infections. Vascular. 2008;16(4):194–200. https://doi.org/10.2310/6670.2008.00041
Published
2025-12-25
How to Cite
1.
Sivash II, Koval BM. NPWT in Complex Surgical Management of Combat Vascular Injuries of the Limbs: Fundamentals of Safe Application and Clinical Experience. ujcvs [Internet]. 2025Dec.25 [cited 2025Dec.26];33(4):136-4. Available from: http://cvs.org.ua/index.php/ujcvs/article/view/802
Issue
Ukrainian Journal of Cardiovascular Surgery Vol 33 No 4 2025
Section
CARDIOVASCULAR SURGERY UNDER MARTIAL LAW