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Autogenous forearm loop arteriovenous fistula creation

Tang WJ, Mat Saad AZ

J Vasc Access, 2018 Mar;19(2):191-194.
PMID: 29148006 DOI: 10.5301/jva.5000801

INTRODUCTION: Arteriovenous fistula is a lifeline for end-stage kidney disease patients on dialysis. The quality of the vein and artery to be used plays a crucial role in attaining a functioning, reliable and long-lasting arteriovenous fistula. The aim of the study is to present an alternative for haemodialysis access to preserve the upper arm vasculature for future use - the forearm loop arteriovenous fistula.
METHODS: From October 2015 to September 2016, 202 patients with chronic kidney disease (CKD), stages 4 and 5, underwent arteriovenous fistula creation at the Universiti Sains Malaysia Hospital, Malaysia. Nine patients, with severe atherosclerosis of the distal artery, but with satisfactory veins, underwent forearm loop arteriovenous fistula creation. Maturation of the fistula was based on the classification by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI).
RESULTS: All nine patients who underwent forearm loop arteriovenous fistula have had diabetes mellitus for more than 10 years. Only one fistula failed to mature within 6 weeks. Two arteriovenous fistulas thrombosed at 3 and 5 months, respectively, after the commencement of haemodialysis. However, the other six matured fistulas are still functioning well after a year of regular usage.
CONCLUSIONS: Distal forearm arteries in diabetics may be severely atherosclerotic. Forearm loop arteriovenous fistula can be considered as the primary access for cases decided as inconvenient for fistula creation due to severe occlusive atherosclerotic disease of the forearm arteries; in order to preserve upper arm veins for future access procedures.
Lower eyelid reconstruction following a traumatic full thickness loss

Tang WJ, Mat Saad AZ

Med J Malaysia, 2017 06;72(3):199-201.
PMID: 28733572 MyJurnal

Eyelid reconstruction is complex and challenging since it is not only for structural and functional restoration, but also for an acceptable aesthetic result. In full thickness eyelid injuries, it will involve both anterior and posterior lamella. Therefore, when reconstructing the defect, it requires at least two layers; one will be a flap with blood supply, and the other can be a free graft. In this case, a rotational advancement cheek flap and composite graft were used to reconstruct the lower eyelid.
Fulltext Successful pregnancy "during" pedicled transverse rectus abdominis musculocutaneous flap for breast reconstruction with normal vaginal delivery

Chai SC, Umayaal S, Saad AZ

Indian J Plast Surg, 2015 5 21;48(1):81-4.
PMID: 25991893 DOI: 10.4103/0970-0358.155276

A transverse rectus abdominis myocutaneous (TRAM) flap is a popular choice for breast reconstruction. Pregnancies in women following a TRAM flap present concerns regarding both safety and the integrity of the abdominal wall. We report a case of a patient who was pregnant during immediate breast reconstruction with pedicled TRAM flap and had a successful spontaneous vaginal delivery. We also conducted a literature review using PubMed on pregnancy post TRAM flap, type of reconstruction, timing of pregnancy after TRAM flap, complication, and mode of delivery, which are summarised in this report. We concluded that patients may have safe pregnancies and normal deliveries following TRAM flap breast reconstruction regardless of the time frame of pregnancy after the procedure. Therefore, TRAM flaps can continue to be a reconstruction option, even in women of childbearing age.
The use of glycerol-preserved skin allograft in conjunction with reconstructive and flap surgery: seven years of experience

Saad AZ, Halim AS, Khoo TL

J Reconstr Microsurg, 2011 Feb;27(2):103-8.
PMID: 20976667 DOI: 10.1055/s-0030-1268208

Major reconstructive surgery may be extensive and prolonged, and it may cause edema and compromise the flap pedicle if closed under tension. Glycerol-preserved skin allograft (GPA) can provide a means for tension-free closure and temporary cover of the wound. Seven years of analysis on GPA used in conjunction with major reconstruction was undertaken to highlight its indications, results, and outcomes. Forty-seven patients were included, aged between 9 and 73 years. Majority of patients had reconstruction following tumor resection and trauma. The main indication for use of GPA was temporary, loose cover of the wound in 44% of cases; flap pedicle protection in 31% of cases; donor site wound cover in 10%; flap monitoring in one case; and management of flap-related complications in 6% of cases. Free flap reconstruction was performed in 72% of cases. In conclusion, GPA is a useful adjunct in reconstructive surgery. It can be used temporarily to allow tension-free wound closure, as well as to protect the flap pedicle until edema subsides and the pedicle becomes stable. This latter approach allows secondary wound closure and good esthetic outcome.
The application of glycerol-preserved skin allograft in the treatment of burn injuries: an analysis based on indications

Khoo TL, Halim AS, Saad AZ, Dorai AA

Burns, 2010 Sep;36(6):897-904.
PMID: 20299154 DOI: 10.1016/j.burns.2009.03.007

Glycerol-preserved skin allograft (GPA) plays a crucial role in the management of burns. Its indications include wound-bed preparation, definitive dressing and sandwich grafting technique.
Fulltext Wound bed preparation for chronic diabetic foot ulcers

Mat Saad AZ, Khoo TL, Halim AS

ISRN Endocrinol, 2013;2013:608313.
PMID: 23476800 DOI: 10.1155/2013/608313

The escalating incidence of diabetic mellitus has given rise to the increasing problems of chronic diabetic ulcers that confront the practice of medicine. Peripheral vascular disease, neuropathy, and infection contribute to the multifactorial pathogenesis of diabetic ulcers. Approaches to the management of diabetic ulcers should start with an assessment and optimization of the patient's general conditions, followed by considerations of the local and regional factors. This paper aims to address the management strategies for wound bed preparation in chronic diabetic foot ulcers and also emphasizes the importance of preventive measures and future directions. The "TIME" framework in wound bed preparation encompasses tissue management, inflammation and infection control, moisture balance, and epithelial (edge) advancement. Tissue management aims to remove the necrotic tissue burden via various methods of debridement. Infection and inflammation control restores bacterial balance with the reduction of bacterial biofilms. Achieving a moist wound healing environment without excessive wound moisture or dryness will result in moisture balance. Epithelial advancement is promoted via removing the physical and biochemical barriers for migration of epithelium from wound edges. These systematic and holistic approaches will potentiate the healing abilities of the chronic diabetic ulcers, including those that are recalcitrant.
Alopecia secondary to repaired occipital encephalocele - role of tissue expander in hair restoration

Ishak A, Mat Saad AZ, Azman WS, Halim AS

Med J Malaysia, 2018 06;73(3):172-174.
PMID: 29962502 MyJurnal

Partial scalp alopecia is a common problem that can lead to severe social and psychological problems. Tissue expansion, although an old concept, provides a surgical alternative to manage areas of alopecia. We describe a case of alopecia secondary to repaired occipital encephalocele that was successfully treated using tissue expansion technique.
An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio-cephalic arteriovenous fistula: A rare presentation of central venous occlusion

Hamzan MI, Hamid AR, Halim AS, Mat Saad AZ

Hemodial Int, 2020 04;24(2):E33-E36.
PMID: 32141217 DOI: 10.1111/hdi.12832

A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical management following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous contralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialysis patients with central venous occlusion is important to prevent unwanted consequences.
Mechanism Action of Platelets and Crucial Blood Coagulation Pathways in Hemostasis

Periayah MH, Halim AS, Mat Saad AZ

Int J Hematol Oncol Stem Cell Res, 2017 Oct 01;11(4):319-327.
PMID: 29340130

Blood is considered to be precious because it is the basic necessity for health; our body needs a steady provision of oxygen, supplied via blood, to reach billions of tissues and cells. Hematopoiesis is the process that generates blood cells of all lineages. However, platelets are the smallest blood component produced from the very large bone marrow cells called megakaryocytes and they play a fundamental role in thrombosis and hemostasis. Platelets contribute their hemostatic capacity via adhesion, activation and aggregation, which are triggered upon tissue injury, and these actions stimulate the coagulation factors and other mediators to achieve hemostasis. In addition, these coordinated series of events are the vital biological processes for wound healing phases. The aim of this review is to summarize and highlight the important pathways involved in achieving hemostasis that are ruled by platelets. In addition, this review also describes the mechanism action of platelets, including adhesion, activation, aggregation, and coagulation, as well as the factors that aid in hemostasis and wound healing.
Fulltext Wound bed preparation from a clinical perspective

Halim AS, Khoo TL, Saad AZ

Indian J Plast Surg, 2012 May;45(2):193-202.
PMID: 23162216 DOI: 10.4103/0970-0358.101277

Wound bed preparation has been performed for over two decades, and the concept is well accepted. The 'TIME' acronym, consisting of tissue debridement, infection or inflammation, moisture balance and edge effect, has assisted clinicians systematically in wound assessment and management. While the focus has usually been concentrated around the wound, the evolving concept of wound bed preparation promotes the treatment of the patient as a whole. This article discusses wound bed preparation and its clinical management components along with the principles of advanced wound care management at the present time. Management of tissue necrosis can be tailored according to the wound and local expertise. It ranges from simple to modern techniques like wet to dry dressing, enzymatic, biological and surgical debridement. Restoration of the bacterial balance is also an important element in managing chronic wounds that are critically colonized. Achieving a balance moist wound will hasten healing and correct biochemical imbalance by removing the excessive enzymes and growth factors. This can be achieved will multitude of dressing materials. The negative pressure wound therapy being one of the great breakthroughs. The progress and understanding on scientific basis of the wound bed preparation over the last two decades are discussed further in this article in the clinical perspectives.
Fulltext Free saphenous venous flap and its modifications: Turbo- and supercharged

Chang KY, Sulaiman WA, Saad AZ

Indian J Plast Surg, 2014 Jan;47(1):147-9.
PMID: 24987224 DOI: 10.4103/0970-0358.129658
Fulltext The versatility of a glycerol-preserved skin allograft as an adjunctive treatment to free flap reconstruction

Mat Saad AZ, Khoo TL, Dorai AA, Halim AS

Indian J Plast Surg, 2009;42(1):94-9.
PMID: 19881027 DOI: 10.4103/0970-0358.53017

Skin allografts have been used in medical practice for over a century owing to their unique composition as a biological dressing. Skin allografts can be obtained in several preparations such as cryopreserved, glycerol-preserved, and fresh allograft. A glycerol-preserved allograft (GPA) was introduced in the early 1980s. It has several advantages compared with other dressings such as ease of processing, storage and transport, lower cost, less antigenicity, antimicrobial properties, and neo-vascularisation promoting properties. Skin allografts are mainly used in the management of severe burn injuries, chronic ulcers, and complex, traumatic wounds. Published reports of the use of skin allografts in association with free flap surgery are few or non existent. We would like to share our experience of several cases of free tissue transfer that utilised GPA as a temporary wound dressing in multiple scenarios. On the basis of this case series, we would like to recommend that a GPA be used as a temporary dressing in conjunction with free flap surgery when required to protect the flap pedicle, allowing time for the edema to subside and the wound can then be closed for a better aesthetic outcome.
Fulltext Chitosan: A Promising Marine Polysaccharide for Biomedical Research

Periayah MH, Halim AS, Saad AZ

Pharmacogn Rev, 2016 Jan-Jun;10(19):39-42.
PMID: 27041872 DOI: 10.4103/0973-7847.176545

Biomaterials created 50 years ago are still receiving considerable attention for their potential to support development in the biomedical field. Diverse naturally obtained polysaccharides supply a broad range of resources applicable in the biomedical field. Lately, chitosan, a marine polysaccharide derived from chitins-which are extracted from the shells of arthropods such as crab, shrimp, and lobster-is becoming the most wanted biopolymer for use toward therapeutic interventions. This is a general short review of chitosan, highlighting the history, properties, chemical structure, processing method, and factors influencing the usage of chitosan derivatives in the biomedical field.
Fulltext Report on von Willebrand Disease in Malaysia

Periayah MH, Halim AS, Saad AZ, Yaacob NS, Karim FA

Open Access Maced J Med Sci, 2016 Mar 15;4(1):112-7.
PMID: 27275342 DOI: 10.3889/oamjms.2016.030

BACKGROUND: Von Willebrand disease (vWD) is an inherited hemostatic disorder that affects the hemostasis pathway. The worldwide prevalence of vWD is estimated to be 1% of the general population but only 0.002% in Malaysia.
AIM: Our present paper has been written to disclose the statistical counts on the number of vWD cases reported from 2011 to 2013.
MATERIAL AND METHODS: This article is based on sociodemographic data, diagnoses and laboratory findings of vWD in Malaysia. A total of 92 patients were reported to have vWD in Malaysia from 2011 to 2013.
RESULTS: Sociodemographic-analysis revealed that 60% were females, 63% were of the Malay ethnicity, 41.3% were in the 19-44 year old age group and 15.2% were from Sabah, with the East region having the highest registered number of vWD cases. In Malaysia, most patients are predominately affected by vWD type 1 (77.2%). Factor 8, von Willebrand factor: Antigen and vWF: Collagen-Binding was the strongest determinants in the laboratory profiles of vWD.
CONCLUSION: This report has been done with great interest to provide an immense contribution from Malaysia, by revealing the statistical counts on vWD from 2011-2013.
Fulltext The outcomes of salvage surgery for vascular injury in the extremities: a special consideration for delayed revascularization

Jagdish K, Paiman M, Nawfar A, Yusof M, Zulmi W, Azman W, et al.

Malays Orthop J, 2014 Mar;8(1):14-20.
PMID: 25279079 MyJurnal DOI: 10.5704/MOJ.1403.012

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries. The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients' limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann's ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.
In vitro capacity of different grades of chitosan derivatives to induce platelet adhesion and aggregation

Periayah MH, Halim AS, Hussein AR, Saad AZ, Rashid AH, Noorsal K

Int J Biol Macromol, 2013 Jan;52:244-9.
PMID: 23063426 DOI: 10.1016/j.ijbiomac.2012.10.001

Chitosan-derived hemostatic agents with various formulations may have distinct potential in hemostasis. This study assessed the ability of different grades and forms of chitosan derivatives as hemostatic agents to enhance platelet adhesion and aggregation in vitro. The chitosan derivatives utilized were 2% NO-CMC, 7% NO-CMC (with 0.45 mL collagen), 8% NO-CMC, O-C 52, 5% O-CMC-47, NO-CMC-35, and O-C 53. Samples of chitosan derivatives weighing 5mg were incubated at 37°C with 50 μL of phosphate buffer saline (PBS) (pH 7.4) for 60 min. The morphological features of the platelets upon adherence to the chitosan were viewed using scanning electron microscope (SEM), and the platelet count was analyzed with an Automated Hematology Analyzer. For platelet aggregation, we added an adenosine diphosphate (ADP) agonist to induce the chitosan-adhered platelets. O-C 52 bound with platelets exhibited platelet aggregates and clumps on the surface of the membrane layer with approximately 70-80% coverage. A statistically significant correlation (p<0.01) for the platelet count was identified between the baseline value and the values at 10 min and 20 min. The results indicate that O-C 53 and O-C 52 were able to promote clotting have the potential to induce the release of platelets engaged in the process of hemostasis.
Fulltext Soft tissue reconstruction following hemipelvectomy: eight-year experience and literature review

Mat Saad AZ, Halim AS, Faisham WI, Azman WS, Zulmi W

ScientificWorldJournal, 2012;2012:702904.
PMID: 22629187 DOI: 10.1100/2012/702904

Hemipelvectomy is a major surgical procedure that associates with significant morbidity, functional impairment, and psychological and body image problem. Reconstruction of the defect is a challenged since a large amount of composite tissues are needed. We would like to share our eight-year experience with massive pelvic resection and reconstruction.
A prospective, randomised, double-blinded trial to study the efficacy of topical tocotrienol in the prevention of hypertrophic scars

Khoo TL, Halim AS, Zakaria Z, Mat Saad AZ, Wu LY, Lau HY

J Plast Reconstr Aesthet Surg, 2011 Jun;64(6):e137-45.
PMID: 20869928 DOI: 10.1016/j.bjps.2010.08.029

Despite widespread beliefs regarding the use of topical tocotrienol in the prevention of hypertrophic scars, there is very little evidence from well controlled and randomised clinical trials to justify its benefits for surgical scars.
Long-term outcome of free fibula osteocutaneous flap and massive allograft in the reconstruction of long bone defect

Halim AS, Chai SC, Wan Ismail WF, Wan Azman WS, Mat Saad AZ, Wan Z

J Plast Reconstr Aesthet Surg, 2015 Dec;68(12):1755-62.
PMID: 26420474 DOI: 10.1016/j.bjps.2015.08.013

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.
Fulltext Blue rubber bleb nevus syndrome in a Malay girl: A case report and literature review

Mat Johar F, Wan Sulaiman WA, Mat Saad AZ, Basiron N, Sahid NA

Int J Surg Case Rep, 2020;72:202-206.
PMID: 32544829 DOI: 10.1016/j.ijscr.2020.05.036

INTRODUCTION: Blue Rubber Bleb Nevus Syndrome (BRBNS) also known as Bean's Syndrome is an atypical type of vascular malformation. To date, around 200 cases have been reported world-wide. In view of its low incidence rate, clinicians might misdiagnose and under treat. The key features of this syndrome are characterized by multiple cutaneous, soft tissue and gastrointestinal tract venous malformations.
PRESENTATION OF CASE: We report the first case of Blue Rubber Bleb Nevus Syndrome in Malaysia, a 23 years old Malay girl who suffers from multiple cutaneous venous malformation and gastrointestinal bleeding episodes.
DISCUSSION: The typical morbidity for this syndrome is symptomatic anemia due to secondary iron deficiency due to the gastrointestinal venous malformation bleeding. In managing the gastrointestinal bleeding, it mainly depends on the severity of gastrointestinal bleeding, some may resolve spontaneously, while the others may be needing blood transfusion, and some may require GIT resections. As for cutaneous lesions, normally it is innocuous depending on the region and size. Large or problematic cutaneous venous malformation might benefit from sclerotherapy or excision.
CONCLUSION: Multidisciplinary approach is crucial in managing BRBNS case due to its complexity and the spectrum of multiple organ involvement to ensure the best outcome to the patient.

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