288 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO.
2, FEBRUARY 2016
Automatic Measurement of Venous Pressure
Using B-Mode Ultrasound
Alessandro Crimi† , Member, IEEE, Maxim Makhinya† , Ulrich Baumann, Christoph Thalhammer,
Gabor Szekely, Member, IEEE, and Orcun Goksel∗ , Member, IEEE
Abstract—Central venous pressure (CVP) information is crucial
in clinical situations, such as cardiac failure, intravascular volume
overload, and sepsis. The measurement of CVP, however, requires
the catheterization of vena cava through the subclavian or internal
jugular veins, which is an impractical and costly procedure with
related risk of complications. Peripheral venous pressure (PVP),
which correlates with CVP under certain patient positioning, can
be measured noninvasively using ultrasound via controlled com-
pressions of a superficial vein. This paper presents an automatic
system for acquiring such noninvasive measurements. Robust sig-
nal and image processing techniques developed for this purpose are
introduced in this paper. The proposed standalone mobile platform
collects images in real time from the display output of any ultra-
sound machine, meanwhile measuring the pressure on the skin
underneath the ultrasound transducer via a liquid-filled pouch.
The image and pressure data are synchronized through an auto-
mated temporal calibration procedure. During forearm compres-
sions, blood vessels are detected and tracked in the images using
robust geometric (ellipse) models, the parameters of which are used
further in the model-based estimation of PVP. The proposed sys-
tem was tested in 56 image sequences on 14 healthy volunteers,
and was shown to achieve measurements with errors comparable
to or lower than the interoperator variability of expert manual
assessments.
Index Terms—Venous blood pressure, real-time tracking, vessel
segmentation, Star-Kalman, dynamic programming.
I. INTRODUCTION
ENTRAL venous pressure (CVP) measurement is a tech-
C nique for monitoring hemodynamics in critically ill pa-
tients and during surgery, e.g., as indications of cardiac failure,
intravascular volume overload, and sepsis. The current stan-
dard technique for CVP measurement is invasive, requiring the
catheterization of a subclavian or internal jugular vein, with
several potential complications, such as vessel rupture and in-
creased rate of thrombosis [1]. An ultrasound-based noninva-
sive method for monitoring CVP without central venous access
has been first proposed in [2] and been evaluated in [3] and
[4]. This method relies on the correlation between peripheral
Manuscript received January 14, 2015; revised June 2, 2015; accepted June
30, 2015. Date of publication July 13, 2015; date of current version January 16,
2016. This work was supported by the Swiss Commission for Technology and
Innovation (CTI). Asterisk indicates corresponding author.
A. Crimi, M. Makhinya, and G. Szekely are with the ETH Zürich.
U. Baumann is with the Münsingen Regional Hospital.
C. Thalhammer is with the Zürich University Hospital.
∗ O. Goksel is with the Computer Vision Lab, ETH Zürich, Zürich 8092,
Switzerland (e-mail: ogoksel@ethz.ch).
† A. Crimi and M. Makhinya contributed equally to this work.
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TBME.2015.2455953
0018-9294 © 2015 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications standards/publications/rights/index.html for more information.
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venous pressure (PVP) and CVP, which allows for indirect CVP
assessment under certain conditions such as the peripheral vessel
being positioned at heart level [5], [6]. A translucent membrane
connected to a manometer is placed in front of an ultrasound
transducer, while the operator gently presses on the skin over
a superficial vein in the forearm. The operator reads the value
on the manometer, while trying to keep the compression at a
point where the vein is seen to barely collapse in the B-mode
image, with the reading then being the subject’s venous pres-
sure. Despite its noninvasiveness, practical difficulties with the
aforementioned measurement procedure prevent a wide use of
this promising measurement technique in daily clinical diag-
nostics. First, it requires an expert operator who can identify a
potential vein and can keep the transducer in line with the vein
during a slow controlled compression. Second, the operator has
to determine a near-complete vein collapse and, by finely adjust-
ing applied pressure, has to keep the vessel barely collapsed in
the ultrasound image, while simultaneously taking a manome-
ter reading such that the measurement is taken at the instant
of collapse. Consequently, subjective and repeatable measure-
ments are difficult, and agreement between observers can be
relatively low. In this work, we introduce an automatic system
for this purpose. This paper presents the signal and image pro-
cessing techniques developed for robust automated noninvasive
measurement of PVP.
Vessel segmentation has been widely investigated in 3-D
medical imaging modalities, e.g., MR/CT angiography and
CT perfusion scans, using various analysis techniques, such
as region growing, active-contours, and particle filtering [7].
For our purposes, we focus here on methods for 2-D vessel
segmentation and temporal tracking in real-time refresh rates.
Vessel tracking in ultrasound has been studied in the literature
for various applications, such as carotid plaque detection [8],
image-servoing ultrasound robots [9], detection of deep vein
thrombosis [10], and guiding jugular vein catheterization [11].
Due to low signal-to-noise ratio of ultrasound imaging, several
vessel tracking approaches in this modality facilitate geomet-
rical vessel models [9]–[11]. We also follow this direction for
venous pressure measurement.
Star algorithm is a common method for the fast approximate
segmentation of convex shapes. It was first introduced in [12]
to track the heart ventricular boundary. This algorithm involves
radial edge-detection along rays emanating from a point inte-
rior to the sought structure, where such seed point is iteratively
reinitialized as the centroid of the extracted structure. In [9],
this method was extended with a Kalman filter for the robust
estimation of continuous radial vessel edge. This uses a rotating
CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND
edge estimator, where the radius is the state of the filter, which is
updated continually by the (noisy) radial edge estimates. Later in
the context of diagnosing deep vein thrombosis in [10], a state-
of-the-art robust tracking was achieved by using an ellipse as a
geometric prior for blood vessels and by employing a Kalman
filter with its state vector being the parametric representation
of this elliptic prior. Vein had to be initialized manually in that
work. Also, the tracking would often fail when the transducer
is moved rapidly or the vessels are nearly/fully compressed; as
demonstrated as well later in this paper in comparisons with
our implementation of their work. Note that a fully collapsed
vein, which does not have a cross section in the image, is very
difficult, if not impossible, to identify even by the naked eye,
let alone by a computer vision algorithm. Consequently, sim-
ple vessel tracking approaches do unavoidably shift to adja-
cent hypoechoic structures, when the actual vessel is collapsed.
Nonetheless, with our proposed approach, it is possible to follow
vessel location during sudden lateral transducer movements—
even while the vein is fully collapsed—thanks to our adoption of
the Lucas–Kanade method [13] for robust interframe global mo-
tion estimation. Furthermore, our interchangeable Star–Kalman
and template matching framework allows us to track relatively
small or nearly compressed veins. Note that tracking is espe-
cially important at the time of compression, which is also when
PVP readings are taken.
Our proposed system simultaneously collects ultrasound im-
ages and pressure readings, and it is devised as an add-on device
for ultrasound machines. It detects veins in the images, tracks
them over time, and estimates the corresponding pressure when
a collapse occurs. Identifying a single moment of vessel collapse
when the pressure should be read [14] can be highly error prone;
therefore, in this study, we employ a novel vein-collapse model
for pressure estimation. This is achieved by utilizing the entire
sequence of vein compression in order to estimate the PVP from
relative changes of the observed vein cross section (e.g., area
or axial radius) and the measured pressure. As the vein should
collapse monotonically with increased pressure, aggregating all
observations throughout a sequence then yields a more robust
estimate of the pressure at collapse. In this way, the detection is
performed simultaneously to tracking and PVP measurement;
and if a tracked object does not exhibit the expected behavior,
then it is discarded or the measurement is reported to the user
as an unreliable reading.
Note that identifying veins in static images is a difficult pro-
cess even for a human observer, not only because several other
structures naturally look hypoechoic in forearm ultrasound im-
ages, but also due to the relatively degraded signal-to-noise ratio
of the images by the pressure measuring pouch in the ultrasound
path. By observing sonographers who perform venous pressure
measurements, it was noted that they typically move the trans-
ducer axially to identify easily compressible structures—that
are the veins. Inspired by this observation, we have developed a
detection-by-tracking approach for identifying veins, also mak-
ing use of the pressure values that are measured independently.
First, a set of hypoechoic candidate structures resembling the
shape of a vein (which is roughly elliptic) are detected via
matching with elliptic templates. From those, the vein is de-
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289
tected as the one fitting the above vein-collapse model—the area
of which decreases with applied skin pressure. This is indeed
similar to computer vision approaches for detecting people in
video sequences, where among objects with human apperance
the ones with human-like behavior are identified [15], [16].
This vein-collapse model is not only used for automatic ini-
tialization, which eliminates the need for a manual vessel ini-
tialization in most cases, but it also helps to detect any false
identification/tracking as explained earlier.
In this study, we present a compact mobile platform that
can attach to any ultrasound system externally to perform au-
tomatic noninvasive PVP measurements. Preliminary results of
this study was presented in [14]. As we also later demonstrate in
our comparisons, several novel contributions presented in this
paper help to make the proposed method robust and superior.
II. METHODS
In an incoming stream of ultrasound images, our proposed
system first detects potential vein candidates (see Section II-A).
These candidates are tracked in the following frames using our
customized Star–Kalman method with elliptic priors (see Sec-
tion II-B), while any abrupt interframe motion is compensated
using a Lucas–Kanade filter (see Section II-C). Using the pres-
sure measurements on the skin, intravenous pressure is estimated
per compression cycle via binning and model fitting to the col-
lected noisy data (see Section II-D). Any initial candidates that
do not follow the expected (compressible) venous behavior are
discarded as false candidates (see Section II-E). These methods
were implemented (see Section II-F) on a standalone mobile
platform, which can attach to any ultrasound machine as an
add-on, where a quick temporal and display calibration routine
enables the adjustment to a particular ultrasound system (see
Section II-G).
A. Initialization
Our methods are aimed to require minimal operator interac-
tion, in order both to be less operator dependent and to ne-
cessitate a lower operator skill level for a wider user base.
Accordingly, in our system, the vein is detected using an au-
tomatic scheme based on observations of physicians searching
for veins. The method first selects a set of candidate (vein-like)
structures, then tracks those while determining their “veinness”
based on their compressional behavior; similar to detection-by-
tracking in the computer vision literature [16]. Often during the
transducer placement process, the sonographers first move the
transducer relatively quickly to ensure proper contact, to evenly
spread ultrasound gel, and to attain the desired orientation and
placement on the forearm; then they slow down to search for
the vein. Accordingly, our candidate selection is performed on
the first frame when both 1) the overall interframe motion is be-
low a motion threshold tm , indicating the above probe placement
stage has been completed, and 2) the pressure goes above a small
pressure threshold tp , indicating the compression has started.
Candidates are selected by template matching using normal-
ized cross correlation (NCC) [17] between an image region of
interest (ROI) and a set of ne binary ellipse templates. ROI
290
Algorithm 1 Vein candidate selection in the image
1: for all rx ∈ [0.5, 4.5] mm do TEMPLATE GENERATION
2: for all ry ≤ rx do
3: Add_Binary_Ellipse_Template(rx , ry )
4: while fi ← Get_Frame() do CANDIDATE SELECTION
5: if Motion(fi , fi−1 ) < tm and pressure > tp then
6: NCCtensor ← Match_All_Templates(fi )
7: for l ← 1..ns do
8: if Max(NCCtensor) > ts then
9: sl ← Pick_Max(NCCtensor)
10: NCCtensor ← Suppress(NCCtensor, sl )
Fig. 1. Sample initialization frame showing four selected candidates with
NCC higher than ts = 0.5.
extends from the bottom of the image to the pouch surface,
found automatically in each frame using its bright reflection.
ne was determined empirically based on the maximum possible
ROI size and the computational capacity of the implementation
platform. Each template contains a hypoechoic ellipse of differ-
ent major/minor radii overlaid on a hyperechoic background of
twice such radii. During template matching, nonmaxima sup-
pression is applied where the higher NCC valued candidate
is kept among any two overlapping ellipses—defined by their
centers being closer than half the sum of their major semi-
axes. Accordingly, a maximum number of ns candidates with
scores higher than an NCC threshold of ts are kept as candi-
dates {s1 , . . . , si } as summarized in pseudocode in Algorithm 1.
These candidates are then all tracked until a compression is ap-
plied, subsequent to which (nonvein) outliers are removed using
the statistical data collected during compression as described
later in Section II-E. Figure 1 illustrates the candidates from a
sample candidate selection stage.
Template matching could in theory be carried out continu-
ously as a vessel tracking approach, not only during initializa-
tion. However, this process is computationally demanding. In
fact, NCC computation for all masks on our hardware takes
up to 250 ms, which causes several next frames to be dropped
from tracking. This is acceptable during candidate selection due
to relatively small interframe motion, which as aforementioned
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IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO. 2, FEBRUARY 2016
Fig. 2. Axis-aligned ellipse model for representing compressing veins.
is already ensured as a criterion (tm ) to start the initialization
procedure. However, such dropped frames were observed to
be detrimental for vein tracking—in particular, during compres-
sions that inherently have faster interframe motion and change of
venous cross-sectional geometry. Therefore, we utilize a much
faster method based on edge detection and model-based tracking
as detailed in the next section.
B. Vessel Tracking
1) Ellipse Model: Similarly to [10], we employ an ellipse
to approximate the cross section of the vein. Rotationally vary-
ing radius of an axis-aligned ellipse centered at the origin (cf.,
Fig. 2) is given in polar coordinates as
rx ry
r(θ) =  (1)
rx2 cos2 (θ) + ry2 sin2 (θ)
for all eccentricity angles θ, where rx and ry are the semiaxes
(radii) along corresponding axes. Accordingly, such ellipses at
arbitrary locations can be represented by four parameters
e = [cx , cy , rx , ry ]T (2)
where cx and cy denote the coordinates of the ellipse center.
In this work, we consider only axis-aligned ellipses for veins,
since this constrained model provides a sufficient approxima-
tion for axially compressing veins, while reducing false-positive
matches compared to those including rotations.
2) Edge Detection: The ellipse representation ei in frame fi
is found based on the ellipse ei−1 from the previous frame as
follows. First, the estimates of potential vessel wall are identi-
fied using edge detection along rays emanating from previous
vessel center (cx , cy )i−1 . For this, the ellipse circumference is
discretized into nr rays at angles θ∈[0, 2π). Along each ray
j∈{1, . . . , nr }, the image is then resampled from the expected
ellipsoid center up to a fixed margin wr outside the expected
edge ri−1 (θj ) at that given angle. The expected values are esti-
mated from previous iteration ei−1 , also using (1). To find the
vessel wall, this search window is correlated with an asymmetric
binary edge profile that has zeros followed (at the sought edge)
by ones corresponding to a fixed margin wb (e.g., [0 · · · 0111]).
This models the vessel wall appearing in images as a set of hy-
poechoic pixels followed by a short hyperechoic edge, whereas
after the wall the tissue may have arbitrary (hypo/hyperechoic)
content depending on neighboring structures. Accordingly, a
NCC value h(θj , ri (θj )) is obtained as an edge response at each
angle/radius sample.
CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND 291

discretized radius estimate at a given angle. Time index i is

dropped here for convenience. Given all possible configurations
Υ, finding the optimal path δ ∗ can be formulated with a smooth-
ness penalty by the following minimization problem:

nr 
nr
δ ∗ = arg min f (θj , r[θj ]) + g (θj −1 , θj ) (3)
δ ∈Υ
j =1 j =2

where the first (unary) term is the data cost, from a point indexed
in Fig. 3, such that

∞, if h(x, y) is undefined (“blue”)
f (x, y) =
−h(x, y), otherwise
Fig. 3. Wall extraction from n r = 60 rays. Gray values indicate edge like- (4)
lihoods given by NCC edge detector discretized at given radii, where the blue and g is the discontinuity penalty of neighboring points as
points indicate infeasible and out-of-range locations. Each column on the left ⎧
indicates a ray profile starting from the ellipse center in the image on the right. ⎪
⎪ 0, if r[θj ] = r[θj −1 ]
Green path is a sample wall extraction with smoothness constraints using dy- ⎨
namic programming (also shown in the image coordinates on the right). The g(x, y) = , if |r[θj ] − r[θj −1 ]| = 1 (5)
red points are the samples that would have been picked without smoothness ⎪
⎪
⎩
constraints. ∞, otherwise
which penalizes high curvature along vessel wall in polar coor-
Even with the robust asymmetric profile above, a continu-
dinates.
ous vessel-wall profile cannot be ensured merely from edge
Using dynamic programming [18], (3) can be solved in linear
responses. In [14], the best edge points along all rays θj were
O(nr wr +nr rx ) time. Specifically, in a first (e.g., left-to-right)
kept for iterative robust ellipse fitting. In [9], several (≈5) best
pass, the cumulative minimum costs are stored on a grid (nodal
edge candidates along each ray were input as r(θ) observations
graph) that is of same size as fi . Then, a backward traversal of
to a Kalman filter rotating around the ellipse repeatedly. Note
minimum costs gives the optimum configuration δ ∗ —the green
that such candidate sampling is not a well-defined problem. In-
path in Fig. 3. Having identified the edge candidates as 2-D point
deed, any n-best strategy leads to a hard decision that, if failed,
locations in the image coordinate frame as in Fig. 3 (right), the
no postprocessing can recover from.
ellipse parameters ei at frame fi are then found using a simple
In this paper, we propose a dynamic programming approach
least-squares ellipse fit. This allows for the tracking of vessel
that takes all edge estimates into account and finds a globally
movements and shape changes.
optimal solution for a vessel wall including smoothness con-
3) Temporal Model: Without any temporal regularization of
straints. For this, consider the problem in polar coordinates as
tracking, a single corrupted/noisy frame or misidentification
in Fig. 3, in which a smooth path (e.g., the green path) from
above would jeopardize the tracking of all following frames.
left edge to right edge is sought. Here, the columns represent
Since the transducer manipulation and the vessel compression
nr rays emanating from vessel center, where pixel gray-values
are kinematic processes, Kalman filtering [19] is, hence, an ideal
are edge responses h at given discrete radii. Blue points indicate
candidate for introducing temporal consistency in our tracking.
infeasible/noncomputed values. The columns here are aligned
Accordingly, we use the above ellipse-fit ei as a (noisy) obser-
at corresponding (expected) radii ri−1 (θj ). This alignment is
vation of a Kalman filter represented by the following dynamic
instrumental in compensating for the periodic radius changes
system:
due to elliptic geometry, which otherwise would yield an (ar- 
tificial) nonsmoothness effect in such polar coordinate frame. xi = Fxi−1 + ζi
In other words, if the ellipse is unchanged (i.e., ei = ei−1 ), (6)
ei = Hxi + ηi
then the optimal profile shall be a line in this frame—not a si-
nusoidal pattern, if such alignment was not done. Maximum where xi = [e∗i ė∗i ] is the Kalman state vector comprising the
likelihood points along each ray based on correlation alone ellipse parameters and their

velocities. A constant state transi-
(without smoothness) are shown in Fig. 3 in red, when they I4 I4
tion matrix F= was used, such that positions/radii are
are different from the optimal (smooth) solution in green. It 04 I4
is seen that simply picking the highest likelihood edge points updated by their velocity. The measurement matrix H=[I4 04 ]
without smoothing is not robust—especially for θ = { π2 , 3π 2 }, relates internal state to observations. The terms ζi and ηi are
where the vessel wall is parallel to ultrasound propagation, and the zero-mean white-noise assumed, respectively, in the process
hence has poorer contrast. and the observations, for both of which the noise covariance
For a fast implementation with global optimality, we de- matrices are internally updated during the filtering process. The
fined the problem as cost minimization with optimal substruc- filter state is updated using conventional Kalman prediction and
ture and solved via dynamic programming. In the discretized correction operations, which yields the tracking result for cur-
edge-response space h in Fig. 3, any wall configuration can rent frame fi as the filtered ellipse e∗i —which is also used in
be represented as δ={r[θ1 ], r[θ2 ], . . . , r[θn r ]}, where r[·] is the Section II-B2 as ei−1 in the next iteration.

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292 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO. 2, FEBRUARY 2016
Fig. 4. Flowchart summarizing the steps of the tracking algorithm, where fi
is the acquired image frame, ei the ellipse observation, and e∗i is the Kalman-
filtered ellipse state with its center (cx , cy ) and the vertical semiaxis ry .
When the vessel is almost compressed and its cross section
is relatively small, the ray sampling and edge detection above
become poorly defined, with some rays not having sufficient
samples for a robust edge detection. Also, the expected center
from previous iteration may then easily fall outside the vessel
for even small transducer movements and vein compressions.
Therefore, when the axial ellipse radius ry is below a preset
threshold tr , the tracking is switched to a template matching
approach. Such tracking works similarly to the candidate se-
lection operation in Section II-A; nevertheless, since the range
of search radii for templates are now much smaller, it is thus,
possible, to perform this at the acquisition frame rate.
C. Motion Compensation
During rapid (sometimes involuntary) motion of the trans-
ducer by the user, the scene may shift too abruptly for the
vessel to be tracked accurately. Hence, for each frame, an addi-
tional motion compensation step is performed using the Lucas–
Kanade method [13]. This estimates a robust globally affine (six
parameter) transformation between frames fi−1 and fi using a
least-squares fit to optical flow estimations at a regular grid of
points seeded under the pouch area. From this transformation,
interframe motion at previous vessel center is sampled, and then,
used to correct (shift) (cx , cy )i−1 prior to the current frame ves-
sel detection procedure in Section II-B2. This helps us to ensure
the Star algorithm to be initialized within the vessel even dur-
ing rapid transducer manipulation. Data flow among the vessel
tracking and motion compensation components are shown in
the block diagram in Fig. 4.
D. Venous Pressure Estimation
Fig. 5(a)–(c) depicts different frames of a tracked vessel,
while it is being compressed. Note that the pressure applied
by an operator, which leads the vein to collapse, may not al-
ways be strictly increasing due to hand/arm dynamics, tremor,
or deliberate operator movements [see Fig. 5(d), in which the de-
picted frames are also marked]. Considering such nonmonotonic
compressions, also complicated by potential measurement and
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vessel tracking errors, we resort to a model of vessel compres-
sion to robustly estimate collapse pressure. Due to the non-
monotonicity, filtering out errors in the space of frames are not
reliable. Also, operators often initially compress a vein rapidly,
and later slowly as the point of collapse approaches. Therefore,
we estimate PVP with a model in the space of pressure versus
vessel cross section, which can be populated and updated from
several observations during a compression. For instance, the
readings in Fig. 5(d) are seen in Fig. 6(a) as the solid line. As
the observations of pressure u from the sensor attached to the
pouch and the ellipse area a from the ellipse tracker are received,
these are statistically filtered by a binning operation. Basically,
for a predefined set of pressure values (bins) uk , which is in this
example { 14 , 34 , 54 , . . .} mbar, a running average mk and a count
nk are kept and updated with each vessel area estimation a. For
each reading, the nearest bin k=arg min|uk − u| is updated as
k
mk ∗ nk + a
mk ← nk ← nk + 1 (7)
nk + 1
with ← being the assignment operator. Bin averages are shown
in Fig. 6(a) as the dashed line, for the given simple example.
Note that in many cases, the user may spend prolonged times
in smaller sections of pressure/area ranges such as performing
several half-complete compressions resulting in loops in such
model space. These are nonetheless effectively smoothed by the
above binning filter that statistically distills those observations.
A polynomial model is then fitted to the binned pressure–
area curves. Of different order of polynomials compared, linear
and quadratic fits had the best estimation of (gold standard)
operator readings on average—with higher worst-case errors
with quadratic fitting. Therefore, we chose linear regression as
our model for a more robust operation. The pressure at the vessel
collapse is then inferred at the intersection of the model with
the x-axis (i.e., a = 0), indicating the moment of vein collapse
where intravenous pressure is overcome. Binned readings and
their linear regression for three consecutive compressions are
seen in Fig. 6(b) in comparison to the gold-standard reading of
9 mbar by the operator.
E. Outlier Removal
The compression model above is also used for the identifi-
cation of actual vein from the set of initial candidates in Sec-
tion II-A. In contrast to other incompressible hypoechoic candi-
date structures, a vein shall compress when pressure is applied.
Then, such a model can help identify veins, even when they are
difficult to resolve from appearance alone. An example is seen
in Fig. 6(c), where the correct vein is clearly recognized from its
behavior (decrease in area) in response to applied pressure, even
though its NCC score from template matching is not the high-
est. Accordingly, following initialization of candidate structures,
all of those are tracked, while building separate pressure–area
curves for each of them. Following a compression, the structure
with minimum slope is recognized as the vein and the others are
discarded from further tracking.
CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND 293

Fig. 5. (a)–(c) Three frames during a vein compression, on which the center and circumference of our tracked ellipse representation are overlaid. (d) Temporal
progression of corresponding pressure values.

Fig. 6. (a) Sample pressure–area curve and its filtered version via binning. (b) Linear regression to binned values from three consecutive compressions. Vertical
lines represent the independent gold-standard reading by a physician. (c) Area change of four candidate structures (seen in Fig. 1) with increasing pressure during a
compression. The actual vein, which has the second highest NCC score from template matching, can still be identified correctly from its behavior (area reduction)
in response to increasing pressure.

The pressure measurement component consists of a flexible

Fig. 7. Proposed hardware consisting of a tablet computer, attached to a frame
grabber and a manometer with a liquid-filled pouch.
F. Implementation
A hardware prototype of our system can be seen in
Fig. 7. The methods introduced above have been imple-
mented in C++ on a tablet computer (Microsoft Surface Pro 2)
with Intel Core i5 dual-core processor with 4-GB memory.
An external frame grabber (VCC-100XUSB-PRO, Vprime
LLC, Beaverton, OR, USA) connected via USB3 interface
is used to acquire high-resolution images from any con-
nected ultrasound machine, through either S-video, video graph-
ics array (VGA), or digital visual interface (DVI) output.
(silicone) membrane attached to a metal frame and filled with
ultrasound-transparent liquid. Having tested several fillings,
vegetable oils (olive oil, in the current setup) have been found to
work best as they match the tissue acoustic impedance well and
cause minimal attenuation. The liquid in the pouch is connected
through a small opening to a pressure manometer circuit (Sen-
sortechnics AG, Puchheim, Germany) inside the handle, which
digitizes liquid pressure values relatively to the atmospheric
pressure. Manometer readings are then sent to the computer via
a USB circuitry (I2C-USB Module, Daventech Ltd., Attlebor-
ough, England) in the pouch handle.
Thanks to the manometer being mounted on the handle, the
relative pressure readings were unaffected from vertical move-
ments of the hand-held component. Nevertheless, rotations of
the pouch do affect the readings as they change the relative al-
titude of the manometer with respect to the silicone membrane.
Therefore, before a series of measurements for each subject,
once a satisfactory arm/vessel location is identified, the trans-
ducer is lifted off the skin keeping its orientation, and a zero
calibration (pressure offset) is performed by touching on the
pressure reading panel. The touch screen also allows the oper-
ator to remove measurements that are deemed to be unreliable
or to override the vein location by touching at a visible vein on
screen. Such override takes precedence over automatic initial-
ization (see Section II-A) and outlier removal (see Section II-E)

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294 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO. 2, FEBRUARY 2016

Algorithm 2 Tracking and pressure estimation

1: while fi ← Get_Frame() do
2: if u < tp and candidates s ≡ {} then
3: Go to CANDIDATE SELECTION in Algorithm 1
4: if u < tp then
5: PVP ← {}
6: Reset_Bins(∀l∈s modell )
7: (mx , my ) ← Estimate_Motion (fi−1 , fi )
8: for all candidates sl do
9: (cx , cy )i ← (cx , cy )i−1 + (mx , my )
Fig. 8. Pressure and membrane displacement (a) before and (b) after temporal
10: if ry < tr then calibration.
11: ei ← Template_Matching (fi , e∗i−1 )
12: else
13: ei ← Star_Algorithm (fi , e∗i−1 )
∗
14: ei ← Update_Kalman_Filter(xi−1 , ei )
15: mk ← Update_Bin(k ← u , a ← e∗i )
16: if a < a40 and PVP ≡ {} then READ PRESSURE
17: for all candidates sl do
18: (modell , errorl ) ← Regression(ml,∀k )
19: s∗ ← Best_Candidate(model∀l,slop e )
20: PVP ← models ∗ |a=0
21: s ← s∗ REMOVE OTHER CANDIDATES Fig. 9. Flowchart depicting the overall data flow and display components.

operations above, and initiates our standard vessel tracking (see
Section II-B) from template matching by few ellipses centered
at that location touched.
In the current implementation, ne = 35 templates are used to
keep the initialization run under 250 ms. For our platform, ne
was determined by testing different discretizations of a maxi-
mum range of [0.5, 4.5] mm minor and [0.5, 11.5] mm major
axes, which cover a wide range of possible vein sizes.
During tracking, the correlation of the estimated ellipse and
the image are kept to indicate the confidence of the current track-
ing state. This tracking confidence is conveyed to the user by
the color of tracking ellipse. Also, if user manipulation (global
interframe motion) is fast, then a speed indicator warns the
user. PVP values predicted from each compression cycle are
displayed immediately in the interface. The above tracking met-
rics, in addition to other error conditions, such as the number
of samples available for model fitting and any resulting fitting
error, are used to infer a final measurement confidence value.
A low confidence is indicated in the interface by coloring the
immediate PVP estimate in red. The median of PVP estimates at
any point is reported to the user as the consensus reading. Last
six estimates with the highest confidence are kept on display for
operator’s perusal. Algorithm 2 gives a simplified overview of
major algorithmic steps; nonetheless, the implementation con-
tains additional sanity checks and flow mechanisms.
G. Spatial and Temporal Calibration
Different ultrasound machines have different screen layouts.
For the first use on a new system, a spatial calibration mode in
our device enables the user to select the relevant image portion
from full screen capture. Since the delays in the ultrasound dis-
play output and our image acquisition pipeline may vary, a tem-
poral calibration mode is also provided to ensure the synchro-
nization between the acquired image frames and the manometer
readings. Temporal calibration is performed by automatically
detecting the pouch membrane displacement in each frame dur-
ing a series of pushes against a hard surface. The system then
analyzes the sequences of pressure values u(t) and membrane
displacements d(t) over time, by computing their NCC [20] to
identify the phase (delay) between them. Basically, if the cross-
power spectrum is computed as the normalized Hadamard prod-
uct of their discrete Fourier transforms, i.e., û◦d̂∗ , then the peak
|û·d̂ |
of its inverse Fourier transform yields the delay to synchronize
the pressure values to images. Pressure and membrane displace-
ment readings for a typical setup are demonstrated before and
after temporal calibration in Fig. 8(a) and (b), respectively.
In our device, a frame buffer and a pressure buffer were im-
plemented to store corresponding information temporarily and
send those to image processing algorithm as needed to ensure the
access to the latest images with corresponding pressure. These
buffers also allow us to record measurement sessions (without
potential dropped frames), as well as to rerun such sessions at
a later time (e.g., with an alternative processing algorithm) by
simply pointing the buffers to load from a file. The data flow
between the buffers, the processing, and the display components
in the graphical user interface (GUI) are shown in Fig. 9.
III. RESULTS
A. Volunteer Study Setup
A volunteer study was conducted in order to evaluate our
vessel tracking and pressure measurement techniques. For this
study, our device was connected externally via the frame grab-
ber to a SonixTouch ultrasound machine (Ultrasonix, Richmond,

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CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND
Fig. 10. Typical measurement setup with the proposed system connected to
an ultrasound machine. The measurement pouch is held with the transducer.
BC, Canada). For measurements, an L14-5/38 linear array trans-
ducer was used together with the hand-held pressure measuring
component as seen in Fig. 10. Ultrasound imaging parameters
were set for superficial vessel examination, with 10-MHz center
frequency and 30-mm imaging depth with a single transmit fo-
cus and dynamic receive focusing. Following our manual screen
calibration, images cropped to a 605 × 473 pixel2 ROI were col-
lected at 30 frames/s from the frame grabber for the entire study.
The temporal calibration yielded an image delay of 140 ms,
which was compensated in the GUI and during automatic mea-
surements. On the given tablet computer, our algorithms run at
≈10 ms per frame on average, of which ≈3 ms is spent on mo-
tion estimation using a 12 × 12 point grid in the Lucas–Kanade
method.
Our study involved 15 healthy volunteers with a median age
of 28 years old and with no history of cardiovascular diseases
or hypertension. The volunteers were placed in supine position,
setting the arm at heart level. For each volunteer, two physi-
cians (called operators below) measured the venous pressure
in a double-blind fashion—each operator twice on the right
forearm at different loci ≈10 cm proximal to the wrist. This
setting allowed us to assess intra and interobserver variability
of manual pressure measurements. In one volunteer with very
small vein cross section, neither operator could locate a superfi-
cial forearm vein around targeted location successfully for PVP
measurement, and, hence, this volunteer was removed from the
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295
Fig. 11. Pressure through a measurement cycle, which consists first of a
conventional reading and then of our new automated measurement protocol.
study. Accordingly, for the remaining 14 volunteers, we had
56 image sequences (measurement cycles) in total to evaluate
our proposed method. Before each measurement cycle, a zero
adjustment of the pressure sensor was performed. The pressure
profile from a sample measurement cycle is seen in Fig. 11, the
acquisition of which is described below.
In a first phase, the operator was asked to conduct a mea-
surement using the current manual technique, called the con-
ventional protocol in the figure. This commonly works such
that the operator slowly compresses the vein to a bare collapse;
then fine-tunes the applied pressure around that point, while
trying to identify the mere instance of collapse in the images;
and, once that is achieved, reads the pressure value (which is
integrated in the GUI in our proposed system, in contrast to a
separate manometer used in earlier studies). Usually, the opera-
tors iterate this process a couple of times to ensure a repeatable
reading, which they then report as the noninvasive PVP of the
subject. Thus, in our study, we had one such value per measure-
ment cycle, which yielded 56 values in total that we used as the
gold-standard PVP measurements for comparisons.
In order to have a technique that can be applied repeatably
and in a short, fixed time-frame by different physicians as well
as other medical personnel such as trained nurses, we have de-
vised a new measurement protocol—also suitable for automated
measurements. As seen in Fig. 11 as the new protocol, the oper-
ator gently and repeatedly compresses the vein, without being
concerned about identifying the instant of collapse. We asked
them to apply three compressions, during which our algorithm
tracked the vein; estimated readings using the pressure–area
model; and, from their consensus, arrived at an automated PVP
measurement for the sequence. Implementation parameters used
in this study are as follows:
tm tp ne ns ts nr wr wb
2 mm/s 1 mbar 35 5 0.5 60 2 mm 0.7 mm
B. Evaluation of Vessel Tracking
Vessel cross section throughout each acquired sequence was
manually segmented separately by two trained annotators in a
blinded fashion to assess interobserver variability of visual iden-
tification of vessels. The vessels are also tracked retrospectively
in the recorded sequences by different versions of our algo-
rithm. For the purposes of the following vessel tracking results,
296
Fig. 12. Per-frame evaluation metrics for three repeated compressions in a sample new-protocol sequence, where the skipped frames correspond to intervals
when the vein is collapsed.
comparisons among different runs are ensured by using the cen-
ter of first-frame annotator segmentations as the (manual) initial-
ization for tracking. Then, in each frame, the vessel identified by
our tracking is compared to each manual segmentation using the
following metrics: Dice similarity [21], Hausdorff distance [22],
Euclidean distance between centroids, and area difference. Dice
and Hausdorff scores are standard segmentation evaluation
metrics that, respectively, measure the normalized overlap and
the worst-case (farthest) border identification error. Addition-
ally, we introduce the latter two metrics, which we purport to be
more relevant for assessing vessel tracking in our application.
Centroid distance tells how far our tracking may wander off
from the vessel, which, if high, will result in the tracking losing
the actual vessel. The last metric, area difference, aims to cap-
ture errors in estimating the vessel cross section, the vanishing
of which indicates vein collapse, and any error therewith would
directly affect our readings through the pressure–area model.
The above metrics for individual frames of a sample sequence
are shown in Fig. 12. The missing values correspond to frames
where the vessel was fully collapsed, and thus, could not be
segmented by the annotator. Note the metrics getting poorer
near such singular points, just before and after compressions,
due to small venous cross section. To evaluate our methods on
all sequences, average metric values are computed as follows.
1) Mean Dice Metric: For manual segmentation Si and au-
tomatic segmentation Ai in each frame fi , an average Dice over
all n frames of a sequence is calculated as
1  2 |Ai ∩ Si |
n
mD = . (8)
n i=1 |Ai | + |Si |
2) Mean Hausdorff Distance: This is a measure of the
longest distance between two subsets of points, i.e., mH,i =
max{ sup inf d(pj , pk ), sup inf d(pj , pk )}, where d(pj ,
p j ∈A i p k ∈S i p k ∈S i p j ∈A i
pk ) is the Euclidean distance between points. The mean Haus-
dorff distance within a sequence is then
1
n
mH = mH,i .
n i=1
3) Mean Centroid Distance: Centroids of cross sections are
computed on fi as (xS i , yS i ) and (xA i , yA i ). Centroid tracking
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IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO. 2, FEBRUARY 2016
error is then the mean Euclidean distance between those as
1 
n
mC = (xA i − xS i )2 + (yA i − yS i )2 . (10)
n i=1
4) Mean Normalized Area Difference: Similarly to the pre-
vious metric, this is computed from the perframe segmentation
areas aS i and aA i as
1  |aA i − aS i |
n
mA = . (11)
n i=1 max(∀i aS i )
The denominator is used to normalize by the maximum area of
the ground-truth segmentation within that sequence.
The distributions of the above tracking metrics for all 56 se-
quences are given in Fig. 13, which demonstrates the improve-
ments from enabling different components of our proposed ves-
sel tracking method (PM). Left-most results in each box plot
were produced by using merely the Star edge detection with
Kalman filtering. The following results demonstrate improve-
ments gained from introducing additional template-based track-
ing, interframe motion compensation, and dynamic program-
ming for ellipse fitting. Our PM by activating all components is
then compared separately to the two manual annotators, A1 and
A2, in Fig. 14. Correlation between vein annotations by these
two annotators is also presented to demonstrate interobserver
variability in this vein identification/tracking task.
C. Evaluation of Pressure Measurement
On each volunteer, each physician took two separate manual
measurements—each time removing the transducer from the
skin and replacing it on a potentially different location. They
performed this by visually observing the manometer readings
themselves (having zeroed the pressure offset) and reported the
resulting (14 × 2 × 2=) 56 values with 0.5 mbar precision. In-
traobserver variability of operators 1 and 2 for their consecutive
readings (taken within few minutes) can be seen in Fig. 15(a)
and (b). The operators were blinded to each other’s readings.
The average of two consecutive readings was taken as that op-
(9)
erator’s judgment of PVP for that volunteer. The comparison of
those PVP judgments between operators is seen in Fig. 15(c) as
interobserver variability. Root-mean-squared error (RMSE) for
intraobserver measurements are 1.07 and 3.7 mbar, respectively,
CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND 297

Fig. 13. Box plots presenting the given evaluation metrics for all sequences from the volunteer study. The results demonstrate incremental improvements
gained from enabling each component of the PM. First, only the Star–Kalman is used, then template matching, next motion estimation (ME), and last dynamic
programming (DP) components are enabled. The distributions include metrics from comparing automatic tracking to both manual annotators.

Fig. 14. Box plots showing tracking evaluation by comparing the PM against ground-truth annotations from annotators A1 and A2.

Fig. 15. (a) and (b) depict the intraobserver variability of operators 1 and 2, respectively, from two repeated measurements of each operator per volunteer. Taking
the average of repeated measurements as the operator’s judgment per volunteer, (c) then shows the interobserver variability. (d) and (e) present the comparisons of
physician assessments to automatic measurements for using the new and the conventional protocols, respectively.

for operators 1 and 2. Interobserver variability has an RMSE of
4.45 mbar.
Our method returns one PVP estimate for each vessel com-
pression, which is combined into a consensus automatic mea-
surement using the median operator. We have compared these
automatic measurements to gold-standard physician assess-
ments, for both conventional and new protocol measurement
sequences. If our algorithm detects a failure of tracking or
pressure–area model, that reading is then removed from the
consensus voting. If no reliable reading can be obtained, that
measurement is reported as fail by the algorithm. With our new
protocol, only one measurement out of 56 could not be acquired
automatically, which corresponds to a 98.2% acquisition suc-
cess. Fig. 15(d) shows the comparison of those 55 successful
readings to physician assessments, which indicates a mean error
of 3.13 mbar and an RMSE of 4.53 mbar, which is comparable
to interoperator variability. We have repeated the evaluation also
using the data from the conventional protocol, which decreased
the measurement mean error to 1.76 mbar and the RMSE to
3.15 mbar as seen in Fig. 15(e). However, the number of failed
measurements increased to 4 (a reduced 92.6% success) due to
the acquisition protocol not being optimal for the processing
methodology. The compression sequences were recorded at the
time of acquisition by the system (by a feature of the frame and
pressure buffers) in order for us to test different methods and
present comparative analyses in these figures.

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298
D. Usability and Interoperability
Following the study, a brief questionnaire was filled by the
participating physicians. The questions are given in the table
below, with their answers collected in a 5-point Likert scale.
Question Operator1
Do you agree with the displayed automatic agree
tracking of veins? (tracking correctness)
System comfortable to use? (ergonomy/comfort) agree
The unified interface with integrated ultrasound agree
and measurement display comfortable? (GUI)
IV. DISCUSSION
A novel automatic noninvasive method for measuring PVP
using ultrasound image analysis has been proposed. This method
can be used as a first-line estimation of CVP without requiring
invasive techniques, such as in hospital emergency units for ini-
tial monitoring of incoming trauma patients. This is similar to
the current use of arterial blood-pressure measurement devices,
but brings in yet another source of diagnostic information as
the venous pressure, which may, for instance, indicate internal
bleeding. Note that achieving measurements from the image
output of different ultrasound machines was a major challenge
addressed by this study. Although this study was conducted on
an Ultrasonix ultrasound machine, we have also tested our de-
vice for PVP measurements with other systems, such as Philips
CX-50, iU22, and Epiq. Our contributions in this study are in-
deed twofolds: a novel technique for real-time vessel tracking,
and a novel automatic method for estimating internal venous
pressure from their collapse pattern.
On the tracking side, our algorithm addresses the challenges
regarding collapsing veins, which virtually disappear from the
image. Also, several techniques that can successfully cope with
reduced image quality due to the measurement pouch and exter-
nal frame acquisition have been developed. Different method-
ological contributions introduced in this study have led to the
presented state-of-the-art vessel tracking results. Fig. 13 demon-
strates how the achieved tracking accuracy has benefited from
each algorithmic proposal. It is seen that template-matching im-
proves average Dice from 0.4 to 0.7, while also improving all
other metrics significantly as smaller/collapsed veins can then be
handled correctly. Motion estimation improves mainly the dis-
tance metrics (Hausdorff and centroid), by boosting finer level
tracking (complicated by erratic movements), nevertheless, it
also improves all metrics overall, since such motion sometimes
leads to complete loss of tracking. With the proposed advanced
vessel wall extraction, mainly the area metric is seen to be im-
proved due to the higher accuracy extraction of the vessel wall,
which also directly affects the pressure estimations. Note that
the order of enabling the techniques was chosen both in the
order they were developed chronologically and also to better
highlight their benefit.
Dice values, even for the interannotator comparison, may de-
grade substantially, in particular, during near-collapse phases,
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IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 63, NO. 2, FEBRUARY 2016
when a very small cross-section results in an unstable metric
especially when segmented differently by the annotators. This
is seen as the near-zero Dice values in Fig. 12(a). That is why we
have proposed alternate metrics for evaluating the given vessel-
tracking task. In particular, normalized area difference (as an
alternative to Dice overlap) quantifies the cross-sectional error,
Operator2 which would affect the pressure estimation through our collapse
model in Section II-D. Note an example between frames 250
agree
and 300 in Fig. 12(a), where a cross-sectional inaccuracy that
agree might affect pressure readings is observed clearly with the rise
strongly in normalized area metric, whereas it is barely discernible in
agree
Dice (a mere drop to 0.7 from 0.9, washed out by other effects).
Similarly, in contrast to Hausdorff metric focusing on vessel
boundary errors, which are less relevant to our specific applica-
tion, centroid difference instead gives a localization error that is
a surrogate for potential tracking loss—similarly to comparing
centers of bounding boxes for tracking error in computer vision.
Note that the veins of patients with circulatory problems may
have different sizes than our volunteers’. This may require fine-
tuning the parametrization for intensive-care applications.
Doppler shift is a common ultrasound modality to image
blood flow. However, it is not utilizable to detect veins in our
scenario due to the minute flow velocities in the superficial
veins, the cross-sectional view required, and the existence of
large motions during compressions.
Our vessel-wall solution in (3) does not enforce continuity
between 0 and 2π, the left- and right-most columns. However,
the addition of this constraint would have jeopardized the opti-
mal substructure, and, hence, our rapid solution. Nevertheless,
the top edge of the vessel, which corresponds to the left- and
right-most columns, is often easily visible, and, thus, those are
mostly defined unambiguously by edge response. This was, in
fact, the motivation behind our choice of θ = 0 ray pointing
upward—the side of wall with high contrast in ultrasound.
Note that the forces on the skin will not necessarily gener-
ate a uniform stress through the tissue due to the geometry of
the forearm and the structure of the tissue. Therefore, the as-
sumption of the internal pouch pressure being equal (or close)
to the venous blood pressure is only valid for superficial veins
and for a transducer placement over those. This assumption
was validated in earlier studies showing the feasibility of this
measurement technique with manual application [2]–[4].
Equipressure on intravenous vessel walls forces the vein to
have a circular cross section, while both the skin tension and the
external pressure applied in the vertical direction in the ultra-
sound image coordinates deform this circle into an ellipse with
shorter vertical axis. Accordingly, we have considered only axis-
aligned ellipses with shorter vertical axis, i.e.. ry < rx , which
successfully modeled all veins tested in this study. However,
not all veins might necessarily be approximated with an ellipse;
such as the veins in-between muscle and other tissue layers may
have different cross sections. Nevertheless, superficial veins in
the forearm, in particular, the cephalic vein near the wrist as
used in this study, are found to be well approximated with an
ellipse. Potentially, operation on veins with thrombosis may be
limited and needs to be studied in the future. Nevertheless, we
foresee that the existence of thromboses may be captured by our
CRIMI et al.: AUTOMATIC MEASUREMENT OF VENOUS PRESSURE USING B-MODE ULTRASOUND
pressure–area model. When the thrombosis is encountered, the
cross section will stop decreasing with the increase in compres-
sion pressure. This can be incorporated in our vessel collapse
model for pressure estimation; nevertheless, future experiments
with synthetic models or patient data are needed to test this.
With the proposed system, automatic readings can be per-
formed quickly and repeatably by different operators. This could
allow trained nurses to perform such measurements similarly to
standard arterial blood pressure measurements. Although the
measurement errors were lower with the conventional protocol,
the number of measurements that could be taken successfully
was lower compared to the proposed new protocol, which con-
sists of repeated controlled compressions, that is simpler, easier,
and repeatable by nonexpert operators. Note that, regardless of
the protocol, over 92% of measurements were computed with
less than 3.13-mbar average error. The compared gold-standard
PVP values were the noninvasive readings by the physicians,
which partially explains the spread in our comparisons (see
Fig. 15) due to the intra and interoperator variability in such
data. Ground-truth PVP readings would be independent mea-
surements taken by an intravenous catheter. Such clinical study
with invasive PVP measurements is planned next.
V. CONCLUSION
An automatic noninvasive technique for measuring PVP using
ultrasound image processing has been presented. Our contribu-
tions in this work are a novel technique for real-time vessel
tracking as well as a novel automatic method for estimating
internal venous pressure from their collapse pattern. We have
presented results from 14 volunteers, while automatic tracking
was compared to vessel segmentations from two annotators, and
the pressure measurements were compared to readings by two
physicians. Results show excellent vessel tracking performance
and satisfactory pressure estimation results, comparable to that
of the interobserver variability. The proposed technique and de-
vice interface is easy to master and has the potential to perform
repeatable user-independent automatic measurements.
ACKNOWLEDGMENT
The authors would like to thank Dr. Radu Timofte for his
valuable discussions on dynamic programming.
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