Cephalic vein in salvage microsurgical reconstruction in the head and neck

The thoracoacromial axis in salvage head and neck reconstructive surgery, a case series

We present the surgical technique, relevant anatomy and a consecutive case series of salvage head and neck free flap reconstructions utilising the thoracoacromial axis. We demonstrated that the thoracoacromial axis is safe and reliable in salvage head and neck reconstruction with particular use in reconstruction of tracheoespophageal and pharyngolaryngectomy fistulae.

Microsurgical scalp reconstruction and cranioplasty refined

Introduction: Microsurgical free flap scalp reconstruction is commonly the only reconstructive option in certain challenging patient cohorts. We describe the technical refinements that have streamlined our ap-proach to microsurgical scalp reconstruction and cranioplasty. Methods: Virtual surgical planning for multiple failed cranioplasty cases involves fashioning an implant with a 3 mm offset. Intramuscular dissection of the latissimus dorsi (LD) vascular pedicle, distal to its bifurcation, is routinely performed, and can increase pedicle length by up to 4 cm without the need for tedious dissec-tion in the axilla. Anastomoses to the superficial temporal vessels distal to their bifurcation in the parietal scalp are reliable and safe. The sequence of surgery is in reverse to the conventional sequence, with the free flap vascularised before craniectomy/cranioplasty is performed to decrease the duration of synthetic im-plant exposure. Results: Thirty-nine cases were performed in 35 patients over a five-year period. An LD-based free flap in various permutations was the commonest free flap option (n = 31). The superficial temporal artery and vein were choice recipient vessels in 82 per cent and 74 per cent of cases, respectively, with the former demon-strating higher anatomical consistency. Complications included free flap venous congestion successfully salvaged (n = 1), infected polymethylmethacrylate cranioplasty requiring explantation (n = 1), subdural haematoma requiring craniotomy for evacuation (n = 1) and free flap donor site haematoma (n = 2). Conclusion: Our technical refinements offer a streamlined and reliable procedure of complex scalp recon-struction and cranioplasty.

Microvascular Flap Reconstruction for Head and Neck Cancers in Previously Operated and/or Radiated Neck: Is It Safe?

BACKGROUND

Microvascular reconstruction after oncologic resection with curative intent in recurrent or second primary cancer cases is challenging not only because of the complexity of the defect but also due to difficulty in finding suitable donor vessels in the neck that has already been subjected to surgery and subsequent adjuvant treatment. In our present study, we evaluated the success of free flaps, reexplorations, and factors associated with reexploration and with flap failures in previously operated and/or radiated neck.

METHODS

In this retrospective study, we analyzed patients who underwent microvascular reconstruction from January 2016 to December 2018 in patients with previous surgery and/or radiation, considered as "already treated neck" (ATN). These cases were reviewed to analyze variables that included age, sex, indication for surgery (recurrence, second primary, osteoradionecrosis, and secondary reconstruction), duration since previous surgery or radiation, free flap done, donor vessels used, the need to go to the contralateral neck or outside the neck, need for vein grafts, flap reexploration rate, flap survival rate, and hospital stay of the patients. We also tried to identify factors that predisposed for a reexploration after performing reconstruction with a free flap in ATN.

RESULTS

Of 1522 free flaps done, 371 patients were included in the study. Flap success rate was 90.8% in ATN, which was comparable to naive neck (94%; P = 0.108). The reexploration rate in ATN (16.2%) was significantly higher (P = 0.0003) than in naive neck (9.8%). The previous treatment (neck dissection) received [P = 0.001; odds ratio, 13.7 (1.87-101.6)] was the most significant predisposing factor, and patients undergoing osteocutaneous flaps were more prone to undergo reexplorations (P = 0.05). Side of anastomosis, vessel used for anastomosis, comorbidities, and time since previous treatment did not affect the reexploration rate significantly.

CONCLUSIONS

Microvascular reconstruction can be safely performed in ATN with good success rates, and it should not be a deterrent in whom free flap is required to achieve best functional outcome. However, it may be associated with increase in reexploration rates in the postoperative period. Patients having undergone a previous neck dissection are at more risk of undergoing this reexploration in comparison with radiotherapy (RT)/chemotherapy and radiotherapy (CTRT) alone.

Common Carotid-to-Internal Jugular Arteriovenous Loop for Single-Stage Microsurgical Reconstruction in the Radiated Vessel-Depleted Neck

ABSTRACT

Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.

Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature

BACKGROUND

Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures.

METHODS

A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications.

RESULTS

The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases.

CONCLUSIONS

Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.

Feasibility and Reliability of Microvascular Reconstruction in the Vessel-depleted Previously Operated Neck

Background:

Microvascular reconstruction of defects in the head and neck has always been a challenge in patients who have undergone previous neck dissection, owing to the prior resection of potential recipient blood vessels used for free flap perfusion.

Objective:

The objective of the study is to evaluate the reliability and safety of free flap reconstruction in patients who have had previous neck dissection.

Materials and Methods:

Twenty-four free flaps were performed in 22 patients with a previous history of neck dissection for head-and-neck squamous cell carcinoma. These included patients who underwent salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction following previous oncological resections. Flap includes 12 radial forearm free flaps, 5 fibula flaps, 1 rectus abdominis flap, and 6 anterolateral thigh flaps.

Results:

In cases with the previous history of selective neck dissection, recipient vessels on the ipsilateral/same side of the previously operated neck were used, while contralateral vessels were used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary, except for one case. In our series, we did not have any flap loss or considerable increase in operative time.

Conclusions:

Free flap reconstruction of head-and-neck defects is highly successful in patients with a history of previous neck dissection, despite a relative scarcity of recipient blood vessels. Careful planning and relying on flaps with a long vascular pedicle obviates the need to perform a suitable vein graft. In our present series, careful planning and the right choice of a free flap with a long vascular pedicle contributes to the absence of free flap failure. In our experience, previous neck dissection should not be considered as a contraindication to microvascular reconstruction of previously operated oncologic defects.

Arteriovenous fistulas for microvascular head and neck reconstruction

BACKGROUND

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

METHODS

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

RESULTS

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

CONCLUSIONS

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

Arteriovenous fistulas for microvascular head and neck reconstruction

Background

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

Methods

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

Results

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

Conclusions

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

Cephalic Vein-Pedicled Radial Forearm Semi-free Flap: An Alternative When no Suitable Vein in Recipient Site for Free Forearm Flap

The risk of venous thrombosis is the main factor of free forearm flap necrosis. In some cases there is no suitable vein at recipient site to provide venous return of the free flap. In this report, two cephalic vein-pedicled radial forearm semi-free flaps were used as an alternative to resurface soft tissue defects in submaxilla and anterior cervical area. The two flaps survived uneventfully. The cephalic vein-pedicled radial forearm semi-free flap could be harvested with a long cephalic vein pedicle, and could be an alternative when there was no suitable or healthy recipient veins at recipient site.

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.

Semi-free radial forearm flap for head and neck reconstruction in vessel-depleted neck after radiotherapy or radical neck dissection

BACKGROUND

Venous thrombosis is the main cause of radial forearm flap failure, especially when recipient vessels are compromised by prior radiation therapy or neck dissection. In such conditions, semi-free radial forearm flap (SF-RFF) can be performed to reduce this risk.

PATIENTS AND METHOD

We reviewed all SF-RFF procedures performed in our institution for head and neck reconstruction. The flap was harvested as a conventional radial forearm flap but the cephalic vein was dissected along the arm up to the deltopectoral crease and used as the sole drainage vein.

RESULT

Seven SF-RFFs were harvested for head and neck reconstructions. The dissection of the cephalic vein lasted less than 25 min in all cases. No flap loss or thrombosis was observed.

CONCLUSION

The SF-RFF is a reliable and versatile procedure for facial, oral, or larynx reconstruction. This hybrid version of the radial forearm free flap is particularly appropriate when no suitable recipient veins are available as a result of radiation or prior surgery.

The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.

Effectiveness of the trapezius vein in the reconstruction of intraoral defects with bare neck

In head and neck cancer reconstruction, the transverse cervical artery is a good alternative vessel when the appropriate recipient vessels cannot be identified because of preoperative radiation and radical neck dissection. Selecting the appropriate recipient vein is essential for a successful intraoral reconstruction. We attempted to determine which veins are candidate partners of the transverse cervical artery by anatomically examining 10 necks (2 sides of the neck in 5 cadavers) in a cadaver study. Three types of veins (suprascapular vein, transverse cervical vein, and descending vein from the trapezius muscle) were selected as recipient vein candidates, and the characteristics of each vein were analyzed. Clinically, we also examined which vessels were chosen as recipient veins in 13 patients in whom intraoral reconstruction with bare neck was performed using the transverse cervical artery as recipient. The descending vein from the trapezius muscles (trapezius vein) was used most frequently, followed by the transverse cervical vein. The transverse cervical vein could be considered an appropriate recipient vein, but it is prone to damage from neck dissection in some cases. Therefore, the use of the trapezius vein can aid in the successful reconstruction in such patients.

Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck

Reconstructions for local recurrence and second primary oromucosal cancer remain a challenge because the recipient vessels are depleted in the neck. The objective of this study was to investigate the outcome of superficial temporal vessels, as reserve recipient vessels for microvascular surgery in vessel-depleted neck patients. Between March 2003 and August 2005, the superficial temporal vessels were used as a recipient site for microsurgical head and neck reconstruction in 15 patients with vessel-depleted necks. There was no flap loss in any of the reconstructions. One venous anastomosis was revised for thrombosis and flap salvaged. The superficial temporal vessels provide a good alternative for head and neck reconstruction in vessel-depleted neck patients with the advantages of radiation spared, constant anastomy, and suitable size. It obviates the need for long pedicle flaps or the use of vein grafts. Care must be taken not to damage or kink the vein.

Ateriovenous subclavia-shunt for head and neck reconstruction

Reconstruction of the facial hard- and soft tissues is of special concern for the rehabilitation of patients especially after ablative tumor surgery has been performed. Impaired soft and hard tissue conditions as a sequelae of extensive surgical resection and/or radiotherapy may impede common reconstruction methodes. Even free flaps may not be used without interposition of a vein graft as recipient vessels are not available as a consequence of radical neck dissection.

We describe the reconstruction of the facial hard- and soft tissues with a free parasacpular flap in a patient who had received ablative tumor surgery and radical cervical lymphadenectomy as a treatment regimen for squamous cell carcinoma (SCC). To replace the missing cervical blood vessels an arteriovenous subclavia-shunt using a saphena magna graft was created. Microvascular free flap transfer was performed as a 2-stage procedure two weeks after the shunt operation. The microvascular reconstructive technique is described in detail.

The thoracoacromial trunk: alternative recipient vessels in reoperative head and neck reconstructive microsurgery

BACKGROUND

Reoperative free tissue transfer in head and neck cancer patients is often a challenging endeavor. Finding adequate recipient vessels for microvascular anastomosis can be difficult, as scar is present from previous surgery and irradiation, and the usual recipient vessels may have been damaged or sacrificed.

METHODS

Seventeen consecutive cases of head and neck reconstruction with free tissue transfer using the thoracoacromial vessels as the recipient pedicle were reviewed. Clinical data were analyzed, including indication for surgery, preoperative radiation dose, previous pectoralis major myofascial flap, free flap design, operative technique, perioperative complications, and follow-up.

RESULTS

Of the 17 cases of free tissue transfer using thoracoacromial vessels for anastomosis, 13 flaps were performed in 12 patients who had received double irradiation. Twelve thoracoacromial trunks used as recipient vessels were in patients with transferred pectoral myofascial flaps. Anastomotic patency was achieved in all flaps.

CONCLUSIONS

The thoracoacromial trunk is a good alternative for recipient vessels in reoperative reconstructive microsurgery of the head and neck when first-line vessels are not available. This choice of vessels is feasible whether or not a pectoralis myofascial flap has previously been used.

Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels

BACKGROUND

Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops.

METHODS

Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17).

RESULTS

Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer.

CONCLUSIONS

Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.

Corlett loop for microvascular reconstruction in a neck depleted of vessels

Free tissue transfer has revolutionised reconstruction of the head and neck and there are currently few local factors that preclude its use. These include a lack of suitable recipient vessels in the area for microvascular anastomosis. We describe the use of a Corlett loop in which a temporary arteriovenous fistula (AVF) is created with a transposed cephalic vein to enable reconstruction of a mandibular defect with a fibular free flap.

A combined anterolateral thigh flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the anterior mandible

The technique of lower anterior facial reconstruction using a combination of an anterolateral thigh flap (ALTF) and a microvascular iliac crest flap is described and the results of 18 cases are reported. Eleven patients suffered recurrence after surgery and radiotherapy of oral squamous cell carcinoma of the lower face. These patients underwent a second surgery and reconstruction. In seven patients reconstruction was performed during primary surgical therapy, followed by postoperative radiotherapy. The pedicle of the ALTF was used for elongation of the iliac crest pedicle. There were no problems with the pedicle length and anastomoses even in patients who had received previous surgery and irradiation of the neck. There was no flap loss. There were no severe postoperative complications. One patient had distant metastases 18 months postoperatively. In all other patients there was no tumour recurrence or metastasis within 10-43 months of follow-up. The ALTF and vascularized iliac bone flap combination is useful in reconstruction of the lower face. The main advantage is the elongation of the iliac flap pedicle by the ALTF pedicle in patients with previous surgery in the neck.

Use of the Internal Mammary Vessels as Recipient Vessels for an Omental Flap in Head and Neck Reconstruction

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE

To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.

SUMMARY BACKGROUND DATA

Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.

METHODS

From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.

RESULTS

There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.

CONCLUSIONS

Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction

Microvascular tissue transfer has become an indispensable procedure for head and neck reconstruction. Although remarkable progress has been made technically, anastomosed vessel occlusion is still a serious complication. Even with technically skilled microsurgeons, anastomosed vessel occlusion occurs because the technique is not the sole prophylaxis against thrombosis in microsurgery. Therefore, to minimize the possibility of an unfavorable result in microsurgery, microsurgeons must be familiar with management options for a vascular compromised flap. Most investigators have agreed that venous obstruction occurs more often than arterial obstruction. Here, we reviewed the published literature on the salvage of venous compromised flaps from the viewpoints of surgical correction, including reanastomosis and catheter thrombectomy, and nonsurgical procedures, such as a medicinal leech, hyperbaric oxygen, and thrombolytic therapy.

In vitro model of intravenous fluid administration: analysis of vein resistance to rapid fluid delivery

Rapid fluid administration is the cornerstone of successful trauma resuscitation of patients in a state of shock. Intravenous (IV) fluid delivery is a physical intrusion into a vein which results in a complex interaction between the rigid catheter and the compliant vein. We present an experimental model of IV infusion into a vein-like compliant tube that (a) demonstrated the interdependence between fluid administration and blood flow in a compliant tube and (b) allowed investigation of the contribution of the central venous system (between the infusion site and the heart) to the total resistance to infusion flow rate. The results show that in cases with very high resistance in the central venous system a significant increase of infusion flow rate cannot be achieved just by increasing the infusion pressure. Similarly, in cases of small veins when only small catheters can be used, infusate flow rate may be increased only by using two independent infusion ports. In cases with increased tissue pressure due to edema, gravity-driven infusion may not produce sufficient perfusion of the vascular compartments. It was also shown that the vein valves do not always close, and that peripheral blood flow may continue together with the infusate fluid (e.g., when there is a small downstream resistance and infusion with a small catheter).