Outflow Routes Research Articles

Uveoscleral Outflow Routes after MicroPulse Laser Therapy for Refractory Glaucoma: An Optical Coherence Tomography Study of the Sclera.

To analyze in vivo scleral changes induced by MicroPulse transscleral laser therapy (MP-TLT) in refractory glaucoma using anterior segment-optical coherence tomography (AS-OCT). Forty-two candidate patients for MP-TLT were consecutively enrolled and underwent AS-OCT at baseline and after six months. MP-TLT success was defined as an intraocular pressure (IOP) reduction by one-third. The main outcome measures were the mean superior (S-), inferior (I-), and total (T-) intra-scleral hypo-reflective space area (MISHA: mm2) and scleral reflectivity (S-SR, I-SR, T-SR; arbitrary scale) as in vivo biomarkers of uveoscleral aqueous humor (AH) outflow. The IOP was the secondary outcome. The relations between the baseline-to-six months differences (D) of DS-MISHA, DI-MISHA, and DT-MISHA and DS-SR, DI-SR, DT-SR, and DIOP, were investigated. At 6 months, the median IOP reduction was 21% in the failures and 38% in the successes. The baseline S-MISHA, I-MISHA, and T-MISHA did not differ between the groups, while S-SR and T-SR were higher in the successes (p < 0.05). At six months, successful and failed MP-TLTs showed a 50% increase in S-MISHA (p < 0.001; p = 0.037), whereas I-SR and T-SR reduced only in the successes (p = 0.002; p = 0.001). When comparing DS-MISHA, DI-MISHA, and DT-MISHA and DS-SR, DI-SR, and DT-SR, there were no significant differences between the groups. In the successful procedures, DIOP was positively correlated with DT-MISHA and DI-MISHA (ρ = 0.438 and ρ = 0.490; p < 0.05). MP-TLT produced potentially advantageous modifications of the sclera in refractory glaucoma. Given the partial correlation between these modifications and post-treatment IOP reduction, our study confirmed that the activation of the uveoscleral AH outflow route could significantly contribute to the IOP lowering after MP-TLT.

Proteomics-Based Identification of Retinal Protein Networks Impacted by Elevated Intraocular Pressure in the Hypertonic Saline Injection Model of Experimental Glaucoma.

Elevated intraocular pressure is considered a major cause of glaucomatous retinal neurodegeneration. To facilitate a better understanding of the underlying molecular processes and mechanisms, we report a study focusing on alterations of the retina proteome by induced ocular hypertension in a rat model of the disease. Glaucomatous processes were modeled through sclerosing the aqueous outflow routes of the eyes by hypertonic saline injections into an episcleral vein. Mass spectrometry-based quantitative retina proteomics using a label-free shotgun methodology identified over 200 proteins significantly affected by ocular hypertension. Various facets of glaucomatous pathophysiology were revealed through the organization of the findings into protein interaction networks and by pathway analyses. Concentrating on retinal neurodegeneration as a characteristic process of the disease, elevated intraocular pressure-induced alterations in the expression of selected proteins were verified by targeted proteomics based on nanoflow liquid chromatography coupled with nano-electrospray ionization tandem mass spectrometry using the parallel reaction monitoring method of data acquisition. Acquired raw data are shared through deposition to the ProteomeXchange Consortium (PXD042729), making a retina proteomics dataset on the selected animal model of glaucoma available for the first time.

Etiopathogensis of Macular Diseases in Terms of Glymphatic Fluid Circulation

This article is an analysis of theoretical aspects of etiopathogenesis of the macular zone of the eye in terms of glymphatic circulation of tissue fluid. To date, a lot of data has been accumulated on functional and structural changes of the macular zone in normal and in various pathologies. The genesis of macular edemas along with subretinal and choroidal neovascularisation could be highlighted and understood from a different point of view if assuming the presence of the glymphatic para- and perivascular fluid flow within the retina, channels in the vitreous body and the choroid. Clinical features of the various eye diseases including hereditary, highlight the paravascular glymphatic outflow routes. As a result of the data analysis, a new theory of disease development in the macular region has been developed for the first time, which explains the pathogenetic mechanisms of occurrence and progression of macular pathology based on the principles of glymphatic current.

Visualising and semi-quantitatively measuring brain fluid pathways, including meningeal lymphatics, in humans using widely available MRI techniques

Brain fluid dynamics remains poorly understood with central issues unresolved. In this study, we first review the literature regarding points of controversy, then pilot study if conventional MRI techniques can assess brain fluid outflow pathways and explore potential associations with small vessel disease (SVD). We assessed 19 subjects participating in the Mild Stroke Study 3 who had FLAIR imaging before and 20–30 minutes after intravenous Gadolinium (Gd)-based contrast. Signal intensity (SI) change was assessed semi-quantitatively by placing regions of interest, and qualitatively by a visual scoring system, along dorsal and basal fluid outflow routes. Following i.v. Gd, SI increased substantially along the anterior, middle, and posterior superior sagittal sinus (SSS) (82%, 104%, and 119%, respectively), at basal areas (cribriform plate, 67%; jugular foramina, 72%), and in narrow channels surrounding superficial cortical veins separated from surrounding cerebrospinal fluid (CSF) (96%) (all p < 0.001). The SI increase was associated with higher intraparenchymal perivascular spaces (PVS) scores (Std. Beta 0.71, p = 0.01). Our findings suggests that interstitial fluid drainage is visible on conventional MRI and drains from brain parenchyma via cortical perivenous spaces to dural meningeal lymphatics along the SSS remaining separate from the CSF. An association with parenchymal PVS requires further research, now feasible in humans.

ICP during head movement: significance of the venous system.

It is thought that the internal jugular veins (IJV) are the primary route for cranial venous outflow in supine position and the vertebral venous plexus when upright. Previous studies have noted a greater increase in intracranial pressure (ICP) when subjects turn their head in one direction compared to the other, but no clear cause had been investigated. We hypothesised that in the supine position, head turning and consequently obstructing the IJV draining the dominant transverse sinus (TVS) would lead to a greater rise in ICP compared to turning to the non-dominant side. A prospective study in a large-volume neurosurgical centre. Patients undergoing continuous ICP monitoring as part of their standard clinical management were recruited. Immediate ICP was measured in different head positions (neutral, rotated to the right and left) when supine, seated, and standing. TVS dominance was established by consultant radiologist report on venous imaging. Twenty patients were included in the study, with a median age of 44 years. Venous system measurements revealed 85% right-sided vs 15% left-sided dominance. Immediate ICP rose more when head turning from neutral to the dominant TVS (21.93mmHg ± 4.39) vs non-dominant side (16.66mmHg ± 2.71) (p= <0.0001). There was no significant relationship in the sitting (6.08mmHg ± 3.86 vs 4.79mmHg ± 3.81, p = 0.13) or standing positions (8.74mmHg ± 4.30 vs 6.76mmHg ± 4.14, p =0.07). This study has provided further evidence that the transverse venous sinus to internal jugular system pathway is the likely primary venous drainage when supine; and quantified its effect when head turning on ICP. It may guide patient-specific nursing care and advice.

An anatomical study of the suboccipital cavernous sinus and its relationship with the myodural bridge complex.

The suboccipital cavernous sinus (SCS) and the myodural bridge complex (MDBC) are both located in the suboccipital region. The SCS is regarded as a route for venous intracranial outflow and is often encountered during surgery. The MDBC consists of the suboccipital muscles, nuchal ligament, and myodural bridge and could be a power source for cerebrospinal fluid circulation. Intracranial pressure depends on intracranial blood volume and the cerebrospinal fluid. Since the SCS and MDBC have similar anatomical locations and functions, the aim of the present study was to reveal the relationships between them and the detailed anatomical characteristics of the SCS. The study involved gross dissection, histological staining, P45 plastination, and three-dimensional visualization techniques. The SCS consists of many small venous sinuses enclosed within a thin fibrous membrane that is strengthened by a fibrous arch closing the vertebral artery groove. The venous vessels are more abundant in the lateral and medial portions of the SCS than the middle portion. The middle and medial portions of the SCS are covered by the MDBC. Type I collagen fibers arranged in parallel and originating from the MDBC terminate on the SCS either directly or indirectly via the fibrous arch. The morphological features of SCS revealed in this research could serve as an anatomical basis for upper neck surgical procedures. There are parallel arrangements of type I collagen fibers between the MDBC and the SCS. The MDBC could change the blood volume in the SCS by pulling its wall during the head movement.

Inferior Frontal Sulcal Hyperintensity on FLAIR Is Associated with Small Vessel Disease but not Alzheimer's Disease Pathology.

The inferior frontal sulci are essential sites on the route of cerebrospinal fluid outflow. A recent study suggests that inferior frontal sulcal hyperintensities (IFSH) on FLAIR images might be related to glymphatic dysfunction. To investigate whether IFSH is associated with Alzheimer's disease (AD) pathology and cerebral small vessel disease (SVD) burden. We retrospectively collected data from 272 non-demented subjects in the ADNI3 database. The IFSH was assessed on 3D fluid-attenuated inversion recovery images. The standardized uptake value ratios of amyloid and tau PET were used to reflect the AD pathology burden. To measure the SVD burden, we assessed white matter hyperintensities (WMH), dilation of perivascular spaces, microbleeds, and lacunes. Finally, we performed ordinal logistic regression analyses to investigate the associations between the IFSH score and AD pathology and SVD burden. The IFSH score was associated with the deep WMH score (OR, 1.79; 95% CI, 1.24 - 2.59) controlling for age and sex. The association remained significant in the multivariable regression models. There was no association between the IFSH score and AD pathology burden. This study suggests that the IFSH sign is associated with SVD but not AD pathology. Further studies are needed to confirm the findings.

The influence of orthostatic test (or verticalization) on the blood flow through the internal jugular and vertebral veins

Highlights. In the absence of venous pathology during verticalization, there is an increase in venous outflow both through the vertebral veins and through the internal jugular veins. In the absence of venous pathology, the internal jugular veins are the dominant route of venous outflow in clinostasis and orthostasis.Aim. To study the dynamics of venous outflow along the internal jugular veins (IJV) and vertebral veins (VV) during the transition from horizontal to vertical position.Methods. The study included 10 healthy women aged 24±2.91 years. Inclusion criteria were as follows: 1) optimal structure of the venous system, in which both of patient`s IJV are approximately symmetrical in cross-sectional area (CSA) and the intensity of the collapse, CSA of IJV exceeds CSA of the common carotid artery by 2–2.5 times, noticeable efficiency of valves during the Valsalva maneuver; 2) venous pressure (VD) in the brachial vein is 18–20 mm Hg. The exclusion criteria were: 1) a history of any disorders of cerebral circulation, symptoms of venous encephalopathy, vertebrobasilar insufficiency, compression of the neurovascular bundle when exiting the chest, arterial hypertension, any cervical spine pathology, hypertrophy and rigidity of the cervical and nodding muscles, 2) arterial pathology of brachiocephalic/intracranial arteries (stenosis, tortuosity, anomalies of the structure), 3) any cardiac pathology, 4) endocrine diseases. The study involved the method of triplex ultrasound with measurements of the cross-sectional areas of IJV, the diameters of VV, time-averaged mean velocity for volumetric blood flow (TAV) in clinostasis and orthostasis. Changes in volumetric venous outflow during verticalization of patients were evaluated as well.Results. In orthostasis, the mean CSA of IJV decreased from 0.862±0.043 cm2 to 0.19±0.024 cm2 , the mean TAV increased from 6.950±2.373 cm/s to 66,000±6.875 cm/s, the average volumetric blood flow increased from 5.952±2.006 mL/s to 12.425±1.559 mL/s. The mean TAV for VV during verticalization increased from 6,800±2.067 cm/s to 16,000±2.271 cm/s, and the average volumetric blood flow from 0.167±0.051 ml/s to 0.402±0.098 mL/s.Conclusion. In all cases, the volumetric blood flow along IJV dominated the volumetric blood flow along VV in clinostasis and orthostasis. In the absence of venous pathology, the dominant pathway of venous outflow in clinostasis and orthostasis are IJV.

Theory of macular diseases in terms of glymphatic fluid circulation

This article is an analysis of theoretical aspects of etiopathogenesis of the macular zone of the eye in terms of glymphatic circulation of tissue fluid. To date, a lot of data has been accumulated on functional and structural changes of the macular zone in normal and in various pathologies. The genesis of macular oedema along with subretinal and choroidal neovascularisation could be highlighted and understood from a different point of view if assuming the presence of the glymphatic para- and perivascular fluid flow within the retina, channels in the vitreous body and the choroid. Clinical features of the various eye diseases including hereditary, highlight the paravascular glymphatic outflow routes. The totality of data on various eye diseases, as well as the revealed clinical features of their course based on the latest scientific data and glymphatic flow in the nervous tissue allowed us to make assumptions about the presence of new physiological patterns of fluid flow in the posterior segment of the eye and formulate a new concept of pathogenesis of macular diseases.

Intraorgan architectonics of hepatic veins in piglets

The liver of animals and humans is characterized by polyfunctionality. All the variety of liver functions and the intensity of their course is determined by the peculiarities of its hemodynamics. According to the morphological anatomy of the pig liver, I distinguish six lobes: the right lateral and medial, the left lateral and medial, square and caudate. The functional anatomy of the liver is based on the division of the liver into segments. In this case, the division is based on the fact that each segment has its own double blood supply, bile and lymph outflow routes. The aim of the study is to study the architectonics of the hepatic veins of newborn piglets, to give a morphometric characteristic of the branches of the intraorgan venous bed, as well as the segmental structure of the liver of piglets. The corpses of newborn piglets of the Landrace breed served as the material for the study. Vasorentgenography, fine anatomical dissection, and morphometry were chosen as research methods. The study included 15 piglets of the newborn period. During the study, it was found that four hepatic veins (right accessory, right, left and middle) flow into the caudal genital vein. Hepatic veins have complex intra-organ architectonics and take branches of the first and second order along their course. The maximum diameter is the left hepatic vein, which carries out the outflow of blood from the left lateral and medial lobes of the liver. The right hepatic vein drains blood from the right lateral and medial lobes, the middle hepatic vein drains from the square lobe, gallbladder and part of the left medial lobe. The smallest diameter is characteristic of the right accessory hepatic vein, which drains the caudate lobe.Having studied the intra–organ architectonics of the branches of the hepatic veins, it can be concluded that the liver of piglets has eight segments - one segment each in the caudate, left medial, right medial and square lobes, two segments each in the left and right lateral lobes.

The peri-olfactory pathway: an "e-scent-ial" route for cerebrospinal fluid clearance?

The peri-olfactory pathway: an "e-scent-ial" route for cerebrospinal fluid clearance?

CSF circulation and dispersion yield rapid clearance from intracranial compartments.

In this paper, we used a computational model to estimate the clearance of a tracer driven by the circulation of cerebrospinal fluid (CSF) produced in the choroid plexus (CP) located within the lateral ventricles. CSF was assumed to exit the subarachnoid space (SAS) via different outflow routes such as the parasagittal dura, cribriform plate, and/or meningeal lymphatics. We also modelled a reverse case where fluid was produced within the spinal canal and absorbed in the choroid plexus in line with observations on certain iNPH patients. No directional interstitial fluid flow was assumed within the brain parenchyma. Tracers were injected into the foramen magnum. The models demonstrate that convection in the subarachnoid space yields rapid clearance from both the SAS and the brain interstitial fluid and can speed up intracranial clearance from years, as would be the case for purely diffusive transport, to days.

Minimally invasive apical cannulation and cannula design for short-term mechanical circulatory support devices

BackgroundRefractory cardiogenic shock is still a major clinical challenge with high mortality rates, although several devices can be used to conquer this event. These devices have different advantages and disadvantages originating from their insertion or cannulation method, therefore many complications can occur during their use. The aim of our study was to develop and create prototypes of a novel minimal invasively insertable, transapical cannula for surgical ventricular assist devices, which uniquely incorporates the inflow and outflow routes for the blood of the patient in itself, therefore it enables the use for only one cannula for patients in cardiogenic shock.MethodsTo define the available space for the planned cannula in the left ventricle and ascending aorta, we analyzed computed tomography scans of 24 heart failure patients, who were indicated to left ventricular assist device therapy. Parallel to these measurements, hydrodynamical calculations were performed to determine the sizes of the cannulas, which were necessary to provide effective cardiac output.ResultsAfter the designing steps, we produced prototypes of double-lumened, tube-in-tube apically insertable devices for three different patient groups, which included a separated venous and an arterial part using 3D modelling and printing technology. All the created cannulas are able to provide 5 l/min circulatory support.ConclusionAs a result of our research we created a sizing method based on the specific analysis of computed tomography pictures of end stage heart failure patients and a cannula concept, which can provide effective antegrade flow for patients in cardiogenic shock. We believe the improved version of our tool could have a significant therapeutic role in the future after further development based on animal and in vivo tests.

Ocular Lymphatic and Glymphatic Systems: Implications for Retinal Health and Disease.

Clearance of ocular fluid and metabolic waste is a critical function of the eye in health and disease. The eye has distinct fluid outflow pathways in both the anterior and posterior segments. Although the anterior outflow pathway is well characterized, little is known about posterior outflow routes. Recent studies suggest that lymphatic and glymphatic systems play an important role in the clearance of fluid and waste products from the posterior segment of the eye. The lymphatic system is a vascular network that runs parallel to the blood circulatory system. It plays an essential role in maintenance of fluid homeostasis and immune surveillance in the body. Recent studies have reported lymphatics in the cornea (under pathological conditions), ciliary body, choroid, and optic nerve meninges. The evidence of lymphatics in optic nerve meninges is, however, limited. An alternative lymphatic system termed the glymphatic system was recently discovered in the rodent eye and brain. This system is a glial cell-based perivascular network responsible for the clearance of interstitial fluid and metabolic waste. In this review, we will discuss our current knowledge of ocular lymphatic and glymphatic systems and their role in retinal degenerative diseases.

Effects of increased intracranial pressure on cerebrospinal fluid influx, cerebral vascular hemodynamic indexes, and cerebrospinal fluid lymphatic efflux

The glymphatic-lymphatic fluid transport system (GLFTS) consists of glymphatic pathway and cerebrospinal fluid (CSF) lymphatic outflow routes, allowing biological liquids from the brain parenchyma to access the CSF along with perivascular space and to be cleaned out of the skull through lymphatic vessels. It is known that increased local pressure due to physical compression of tissue improves lymphatic transport in peripheral organs, but little is known about the exact relationship between increased intracranial pressure (IICP) and GLFTS. In this study, we verify our hypothesis that IICP significantly impacts GLFTS, and this effect depends on severity of the IICP. Using a previously developed inflating balloon model to induce IICP and inject fluorescent tracers into the cisterna magna, we found significant impairment of the glymphatic circulation after IICP. We further found that cerebrovascular occlusion occurred, and cerebrovascular pulsation decreased after IICP. IICP also interrupted the drainage of deep cervical lymph nodes and dorsal meningeal lymphatic function, enhancing spinal lymphatic outflow to the sacral lymph nodes. Notably, these effects were associated with the severity of IICP. Thus, our findings proved that the intensity of IICP significantly impacts GLFTS. This may have translational applications for preventing and treating related neurological disorders.

Drainage glaucoma surgery

Glaucoma is a chronic disease characterized by optical neuropathy, progressive degeneration of retinal ganglion cells and nerve fiber layer, and is the leading cause of irreversible blindness in the world. Currently, the most reliable way to achieve stable normalization of intraocular pressure is surgical treatment, and its success is measured by the duration of the hypotensive effect. However, surgical interventions do not always have a prolonged effect. One of the most drastic and effective ways of treating patients with glaucoma is surgery involving installation of a drainage implant. The use of implants in the area of surgical intervention is the most effective way to preserve the outflow routes of intraocular fluid created during antiglaucoma interventions. The use of implants is aimed at reducing excessive scarring in the filtration zone and at creating ways of resorption of intraocular fluid. In the history of glaucoma surgery, numerous designs for drainage implants have been proposed, differing from each other in material, drainage structure, implantation technique, and results. This literature review describes the types of anti-glaucoma drainage devices and their latest modifications, and presents the statistics of postoperative complications and long-term results of the use of foreign- and Russian-made implants in the treatment of glaucoma.

Bleb-Independent Glaucoma Surgery to Activate the Uveolymphatic Route of Non-Trabecular Aqueous Humor Outflow: Short-Term Clinical and OCT Results.

The deep sclerectomy technique was modified to enhance aqueous humor (AH) outflow via the non-trabecular pathway. A pilot study was carried out to assess its safety and effectiveness. Thirty-eight patients were under observation. After superficial scleral flap (4 × 4 mm), deep scleral layers were divided into three parts by three parallel-to-limbus incisions. Deep sclerectomy without creating a window in the Descemetes’ membrane was carried out in the distal part. A collagen implant was placed under the sclera of the remaining two parts with one end in the intrascleral pool. The third proximal part was excised to expose the uvea and implant. A Nd:YAG laser trabeculotomy at the surgery site was made on postoperative days 7–10. Outcome measures were IOP change, use of hypotensive medication(s), complications, and the need for a second surgery. At six months, the mean IOP decreased from 29.1 ± 9.2 mm Hg to 14.0 ± 4.3 mm Hg (p = 1.4 × 10−9); hypotensive medication use reduced from 2.9 ± 0.9 to 0.6 ± 1.0 (p = 1.3 × 10−10); complete success was achieved in 68.4% of cases and partial success was achieved in 31.6% of cases. Intraoperative and postoperative complications were rare and manageable. The OCT of the surgery site revealed the absence of bleb in all cases. Lymphatic vessels with characteristic bicuspid valves in their lumen were detected in conjunctiva near the operation site and over it in 32 patients. IOP decrease in the proposed technique was achieved by activation of the uveolymphatic route of AH outflow.

Comparisons of Schlemm's canal and trabecular meshwork morphologies between juvenile and primary open angle glaucoma

The histologic differences in Schlemm's canal (SC) and trabecular meshwork (TM), obtained from the trabeculectomy specimens of different age-group glaucoma patients, were compared. This study involved 44 trabeculectomy specimens of 37 juvenile-onset open-angle glaucoma (JOAG) patients (Group A) and 24 trabeculectomy specimens of 24 elderly-onset primary OAG (POAG) patients (age range: 70–79 years, Group B) with no familial history of POAG. Clinical parameters of gender, maximum intraocular pressure (IOP), and the number of glaucoma medications used prior to trabeculectomy were investigated and compared between the two groups. From light microscopy photographs of hematoxylin-eosin, and immunohistochemical staining of markers for SC endothelium (SCE), the total SC length (TSC), comprised of the opened-SC length (OSC) and the closed-SC length (CSC), the percentage of CSC in TSC (%CSC), the percentage of positive SCE marker in CSC (%PinCSC), and the percentage of negative SCE marker in OSC (%NinOSC) were analyzed. Moreover, podoplanin staining patterns in the TM were investigated and compared between the two groups. Among the clinical parameters, the mean maximum IOP in Group A (33.41 ± 9.24 mmHg) was the only significant parameter when compared to that in Group B (22.96 ± 7.17 mmHg, P = 0.000003). TSC in Group A was significantly shorter than that in Group B (P = 0.00092), and %CSC (P = 0.00004) and %PinCSC (P = 0.00342) in Group B were significantly higher than those in Group A. No statistically significant difference in %NinOSC was found between Group A and Group B (P = 0.76060). Juxtacanalicular tissue (JCT) in Group A showed compact and weak staining with podoplanin, while the JCT and closed-SC area in Group B showed intense staining. In the Group A subjects, TSC (P = 0.04819) and OSC (P = 0.02867) were significantly shorter in the non-familial cases than in the familial cases. Platelet coagulations 10–37 μm in size at the defect of the SCE in the inner wall of the SC were observed in 8 eyes (18%) and 4 eyes (17%) in Group A and Group B, respectively. The platelets appeared to repair the SCE damage for maintaining the blood aqueous barrier in both groups of POAG eyes. Smaller SC diameters and accompanying TM abnormality were features observed in the young-onset JOAG patients, thus suggesting developmental abnormalities in the outflow routes. The collapse of SC lumen, presumably due to aging, was the feature observed in the elderly-onset POAG patients. In Group A, the significantly higher IOP, despite of no significant number of topical medications used prior to trabeculectomy, also suggested that JOAG eyes can be categorized as a distinct type of POAG from the eyes of elder-aged POAG patients. The SCE drop out observed in the glaucomatous eyes of the different age groups suggested that worsening of IOP control may possibly occur equally in both groups.

Abnormal anastomosis of peripheral pulmonary arteries, initially suspected to be an arteriovenous fistula, in an adult with Williams syndrome.

Key messageAbnormal anastomosis of peripheral pulmonary arteries is rare and resembles a pulmonary arteriovenous fistula; thus, when the inflow or outflow route cannot be clearly identified in a suspected pulmonary arteriovenous fistula, the possibility of peripheral pulmonary artery anastomosis should be considered. However, the final diagnosis requires a catheterization study.

Anatomia chirurgiczna gruczołu piersiowego. Unaczynienie, unerwienie, drenaż limfatyczny, budowa dołu pachowego. Część druga.

Dynamically developing oncoplasty, i.e. the application of plastic surgery methods in oncological breast surgeries, requires excellent knowledge of mammary gland anatomy. This article presents the details of arterial blood supply and venous blood outflow as well as breast innervation with a special focus on the nipple-areolar complex, and the lymphatic system with lymphatic outflow routes. Additionally, it provides an extensive description of the axillary fossa anatomy.