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NEGATIVE PRESSURE WOUND THERAPY IN DIABETIC FOOT WOUNDS ■ 115betic feet without ischemia. A range of advantageswas demonstrated when comparedwith conventional therapy (saline gauzealone), and includes improvements in thespeed of granulation tissue formation,decrease in wound dimensions, time to healing,cost of treatment and rate of amputations.In general, an improved chance of fasterhealing with grade 1 diabetic foot ulcers isobserved with the application of NPWT,which may not be immediately warranted inthese wounds (19).Certain wound types may benefit moresignificantly from application of NPWT thanothers, as is the case of larger and olderwounds (more than one year in duration),which are less likely to achieve a positive outcomewith conventional therapy. When thesewounds are treated with NPWT, their ratesof healing are closer to the results obtainedwith the smaller and more recent wounds(20).With respect to the duration of NPWT,several publications favour wound closure bysecondary intention (21, 22) (Figure 2), sinceFigure 2. Wound resulting from amputation of the 3 first toes: 4 days after the surgery (A); 30 days aftersurgery and 25 after the beginning of NPWT (B); 5 months later, secondary intention healed wound (C).it has been shown to improve the rate of closureand reduce the time to healing. However,the use of NPWT until complete wound closure,which lasts for a relatively long period oftreatment, has an important impact on thepatient’s quality of life and overall cost of therapy.Therefore, NPWT can also be used as abridge to surgical grafting (23), increasing thespeed of granulation tissue formation until thewound becomes a good candidate to receive askin graft. This strategy may reduce the lengthof hospital stay and the cost of therapy.Ischemic foot ulcersMost published studies regarding diabeticfoot ulcers describe results following NPWTin adequately perfused limbs. However, it iswell recognized that diabetic patients typicallyhave tibial and peroneal arterial occlusivedisease and ischemia results from atheroscleroticmacrovascular disease besides themicrocirculatory dysfunction (24). The use ofNPWT on ischemic limb wounds is a highlyspecialized clinical scenario since in theabsence of adequate blood perfusion, normalwound healing process cannot proceed (25).Therefore, revascularization is undoubtedlythe best intervention to achieve limb salvagein patients with limb ischemia.After successful revascularization, NPWTmay be considered as an advanced woundcare therapy for lower limb ulcerations (18).In such cases, it has demonstrated to signifi-