Structural and Functional Salvaging of Traumatic Brachial Artery Cut with Multiple Nerve Cut: Case Series Upper limb arterial injury is relatively rare among trauma cases. Among them, the majority is contributed by brachial artery injury. Brachial artery injury is associated with nerve injuries given that its anatomical course, which brings a significant impact to the patient. We reported 2 cases of patients who sustained a deep laceration wound over the right upper limb. Both presented to the Emergency department with active bleeding over the wound, and clinically cold right hand, associated with absent radial and ulnar pulses with profound sensory and motor deficit. Wound exploration and brachial artery repair with reverse saphenous vein interposition graft, followed by structural and nerve repair. This case series highlighted the importance of prompt detection and intervention of brachial artery injury. Any further delay might result missing the golden hour of revascularization for the patients. It also showed the importance of consideration of limb salvage in a patient who was deemed Rutherford III, especially nerve cut was uncertain. In conclusion, prompt intervention of traumatic brachial artery injury and proper intraoperative assessment are mandatory to properly decide if a limb is salvageable or not.

Appendicitis or Not Appendicitis: A Case Report of Acute Appendicitis Complicated with Disseminated MSSA and Iliopsoas Abscess This case report describes a 17-year-old female with acute appendicitis complicated by Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteremia and an iliopsoas abscess. Initially presenting with right iliac fossa pain and fever, she was diagnosed with acute appendicitis and underwent appendectomy. Postoperatively, she developed persistent fever and hip pain. Imaging revealed an abscess in the right iliacus muscle, which was drained percutaneously. MSSA was identified in the abscess culture. The patient recovered with targeted antibiotics. This case highlights the diagnostic challenges and importance of considering secondary infections in postoperative patients with atypical symptoms. Prompt recognition and treatment are essential for positive outcomes.

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of <1%. This is due to the advancements and wide availability of ultrasound to guide its insertion. Formation of arteriovenous fistula after arterial puncture is an unexpected complication. Till date, only five cases (including this case) of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture. The present case is a 26-year-old man sustained traumatic brain injuries, chest injuries and multiple bony fractures. During resuscitative phase, attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery. Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula. The catheter was removed successfully and common carotid artery was repaired. Postoperatively, the patient recovered and clinic visits revealed no neurological deficits. From our literature review, the safest method for removal is via endovascular and open surgical removal. The pull/push technique (direct removal with compression) is not recommended due to the high risk for stroke, bleeding and hematoma formation.

Venous malformations (VM) of vulva, perineum and pelvis are uncommon condition which may present with cutaneous varices or aesthetically disabling swelling of external genitalia. Herein, we report a young woman who presented with a large left vulva bluish tinged swelling, progressively increasing in size since birth. Computed tomography of the pelvis and lower limbs confirmed the diagnosis of extensive VM of pelvis and perineum. She underwent selective angiogram which revealed venous malformations of left vulva and gluteal region with no arterial supply to the lesion. Surgical excision was performed but complicated with bleeding which necessitate multimodal hemostatic procedures and blood transfusion. There is no recurrent swelling after 5 years follow up. Surgical excision of vulvar venous malformation offer good cosmetic outcome. However, appropriate planning with axial scan, angiogram and operative technique including multimodal hemostatic measure are important steps to achieve good result with no recurrence. We discussed on challenges on management of this case in relation to the currently available literature.
Vascular Malformations ; Perineum ; Pelvis

Leiomyosarcoma of the Inferior Vena Cava (IVC) is a rare soft tissue tumour which accounts for only 0.5% of all soft tissue sarcomas. The patients usually presented with non specific clinical signs and often diagnosed at advanced stage. We reported a case of a 58-year-old lady who presented with right sided abdominal pain for 6 months. CT scan showed large Level 2 IVC tumour which encased the right renal vein and had no clear plane of demarcation with the caudate lobe of the liver. She underwent radical resection of the IVC tumour with the right kidney removed en bloc. Vascular reconstruction was not performed as established collateral veins present. She was nursed in Intensive Care Unit for 2 days and discharged well at day 5 post operatively. Histopathological examination results revealed leiomyosarcoma of IVC.

Cystic hygroma or cystic lymphangioma is a congenital malformation of lymphatic origin. Their occurrence on the chest wall is very rare, and they progressively grow with age infiltrating into the local tissues, around muscle fibers and nerves, making them difficult and hazardous to remove. There are various treatment modalities of such lesion. Based on the literature surgical excision is the preferred treatment of choice in cystic hygroma because it gives a better cure rate compared to other modalities. We report a case successful excision of anterolateral chest wall cystic hygroma in a teenager in Hospital Serdang. KEY WORDS: