02/08/2025
Doppler Ultrasound Part 2:
VExUS Made Easy: 4 Simple Steps to Assess Venous Congestion
By Aj. Nuttha
https://youtu.be/1GHvs4QITAk
1. Start with the IVC (Inferior Vena Cava):
Use a subxiphoid view in short axis via liver window
Measure IVC 1–2 cm below the RA–IVC or HV–IVC junction
Long-axis shows IVC connecting to RA and hepatic vein
IVC 2 cm or less = VExUS Grade 0 (Asian patients may need a lower cutoff)
Use B-mode or M-mode to check collapsibility
2. Assess the Hepatic Vein (HV):
Use subxiphoid or coronal view
Place Doppler gate 1–2 cm into the HV, away from junction
Ask patient to hold breath at end-expiration
Doppler waveforms:
A-wave (retrograde) = atrial contraction (P wave)
S-wave (antegrade) = systole (QRS)
V-wave (retrograde) = end-systole
D-wave (antegrade) = diastole (after T wave)
Normally S is greater than D. In congestion, S weakens or reverses
3. Evaluate Portal Vein (PV):
Use coronal view near the right kidney
Color Doppler shows continuous red flow toward the probe
Pulsatility Index (PVPF = max minus min, divided by max):
Under 30 percent = Normal
30 to 50 percent = Mild congestion
Over 50 percent = Severe
Flow reversal = Very severe congestion
4. Check Intrarenal Veins (IRV):
Scan in coronal view over the kidney
Use color Doppler: red = arterial, blue = venous
Place PW Doppler on interlobar or arcuate veins
Normal = smooth, continuous flow with little pulsatility
Congestion = interrupted, pulsatile flow with distinct S and D
waves
Use arterial waveform to match with cardiac phases
VExUS Simplified: A Step-by-Step Guide to Assessing Venous Congestion1. Start with the IVC (Inferior Vena Cava):Use a subxiphoid view in short axis via liver...
