ACKD

VExUS Nexus: Bedside Assessment of Venous

Congestion
Eduardo R. Argaiz

Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pres-
sure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been
increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic conse-
quences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdom-
inal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with
congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the
bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal
Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in
the management of patients with venous congestion.
Q 2021 by the National Kidney Foundation, Inc. All rights reserved.
Keywords: POCUS, Portal vein pulsatility, Venous congestion, Cardio-renal syndrome, Intrarenal venous Doppler

CASE driving kidney dysfunction and adverse outcomes in this

A 47-year-old female with a past medical history of pulmo-
nary arterial hypertension (group 1), severe tricuspid
regurgitation and right ventricular (RV) dysfunction was
referred to the emergency department with an increase
in serum creatinine (0.71 to 2.3 mg/dL). She was recently
seen in the pulmonary hypertension clinic where she
was started on oral diuretics because of lower extremity
edema. On interrogation, she feels fatigued but denies
increased shortness of breath. Her medications include sil-
denafil, bosentan, furosemide, and spironolactone. Blood
pressure was 89/62 mmHg with a heart rate of 96 bpm.
Physical examination was notable for CV wave fusion on
jugular venous pressure (JVP) examination, a holosystolic
murmur at the left lower sternal border, and lower extrem-
ity edema. Capillary refill time was , 1 second. Urinalysis
did not show proteinuria or hematuria with a specific
gravity of 1.020. Urine sediment was bland and urinary so-
dium was 14 meq/L. Point-of-care ultrasonography re-
vealed a normal lung ultrasound (A-Profile) and the
inferior vena cava diameter was 2.7 cm with no respiratory
variation. What would be the next step in the evaluation
and management of this patient?
Acute decompensated heart failure (ADHF) is character-
ized by hemodynamic derangements that include low car-
diac output (“forward” failure) and elevated cardiac filling
pressures (“backward” failure”).1 It is increasingly recog-
nized that elevated filling pressures, rather than reduced
cardiac output, is the primary hemodynamic factor
From the Department of Nephrology and Mineral Metabolism, Instituto Na-
cional de Ciencias M
edicas y Nutrici
on Salvador Zubir
an, Tlalpan, Mexico City,
Mexico.
Financial Disclosure: The author declares that he has no relevant financial
interests.
Address correspondence to Eduardo R Argaiz, MD, PhD, Department of
Nephrology and Mineral Metabolism Instituto Nacional de Ciencias M
edicas
y Nutrici
on Salvador Zubir
an Vasco de Quiroga No. 15, Tlalpan 14080, Mexico
City, Mexico. E-mail: lalo.argaiz@gmail.com
Ó 2021 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
https://doi.org/10.1053/j.ackd.2021.03.004
patient population.2,3 Because the kidney is an encapsu-
lated organ, transmission of central venous pressure to
the renal veins increases tubular and interstitial hydro-
static pressure leading to impaired GFR.4 This pressure
can also result in vessel compression and altered paren-
chymal venous compliance leading to altered patterns of
venous flow.5
Early invasive detection of increased cardiac filling pres-
sures and venous congestion leads to decrease exacerba-
tions and hospitalizations in patients with congestive
heart failure (CHF).6 However, the optimal strategies for
noninvasive evaluation of venous congestion are still
being developed. The evaluation of venous congestion re-
lies on physical examination findings that can be insensi-
tive or poorly reproducible even among experienced
clinicians.7-9 Although JVP usually reflects right atrial
pressure (RAP), measurement is often limited by body
habitus or respiratory pathology. Certain conditions such
as severe tricuspid regurgitation render JVP examination
less useful.9
Natriuretic peptides are secreted in response to increased
wall tension caused by volume and pressure overload.
However, they are of limited use given levels are influ-
enced by several factors such as age, BMI, sepsis, pulmo-
nary disease, and kidney dysfunction even in the
absence of cardiac disease.10 Another limitation is that
the change in natriuretic peptide levels lags behind acute
changes in hemodynamic measurements.11 Although
bioelectrical vectorial impedance analysis has been pro-
posed as an aid to evaluate body hydration status in
CHF,12 this technique cannot be used to assess venous
congestion as it does not factor in cardiac filling pres-
sures.13
Point-of-Care Ultrasound in the Evaluation of Venous
Congestion
Currently there are several widespread point-of-care ultra-
sound (POCUS) applications for managing congestion in
patients with CHF.14 Assessment of extravascular lung
fluid secondary to increased left cardiac filling pressures
can be performed with lung ultrasound (LUS) by

252 Adv Chronic Kidney Dis. 2021;28(3):252-261

 Assessment of Congestion Using POCUS 253

quantification of “B-Lines” arising from the pleural line.15 marker is directed toward the patient’s head (Fig 2). Color
The addition of LUS in the management of patients with Doppler imaging scale should be adjusted to low flow ve-
heart failure has been shown to decrease decompensations locities (20-30 cm/s); this can also be achieved by selecting
and urgent heart failure visits.16,17 Despite its usefulness, the abdominal preset on the ultrasound machine. The he-
LUS does not evaluate the effect of congestion on the patic and portal veins are sampled with pulsed wave
abdominal compartment which contributes significantly Doppler at the end of an expiratory hold while avoiding
to deranged cardiac and kidney function in CHF and is the Valsalva maneuver.30 Conventionally, blood flow
18,19
especially relevant to patients with right heart failure. directed toward the ultrasound probe will display a posi-
POCUS allows a semiquantitative assessment of RAP by tive velocity while flow directed against the probe will
evaluating the size and collapsibility index of the inferior display a negative velocity on the Doppler waveform.31
vena cava (IVC).20 The short axis view to assess both the Simultaneous ECG recording allows the signal to be syn-
short and long diameter of the IVC has been shown to be chronized with the cardiac cycle. For the intrarenal venous
a more reliable estimate of the central venous pressure Doppler, the probe is displaced caudally and posteriorly to
(CVP).21 Because of this, POCUS evaluation of the IVC render a longitudinal view of the kidney. Color Doppler
can be used as a good starting point in the evaluation of imaging scale should be lowered further (less than
abdominal venous congestion.22 20 cm/s) and the interlobar veins should be identified.
Organ dysfunction occurring with venous congestion is, The best aligned interlobar vein should be sampled with
however, not only related to increased RAP, but also to the pulsed wave Doppler at the end of an expiratory hold.32
4
transmission of pressure to the peripheral organs. Trans-
mission of pressure alters the pattern of venous blood Hepatic Vein Doppler Interpretation
flow in a predictable way and these alterations can be HV are located in the immediate vicinity of the IVC; thus
quantified using venous Doppler.23,24 Thus, as opposed normal flow in the HV is pulsatile and mirrors changes
to other POCUS applications in the assessment of CHF, in the CVP during the normal cardiac cycle (Fig 3A). The
venous Doppler might allow normal HV waveform is
an improved evaluation of CLINICAL SUMMARY composed of two distinct
congestive organ injury antegrade waves (flow
(Table 1). from the liver to the heart)

Backward transmission of elevated right atrial pressure
causes abdominal organ congestion, which can lead to and two retrograde waves
organ disfunction (congestive nephropathy). (flow from the heart to the
Transmission of Right liver).25 Because of the posi-
Atrial Pressure Alters
Worsening degrees of congestion cause progressive tion of the ultrasound
Venous Blood Flow alterations in organ venous flow that can be quantified
probe, antegrade waves
using color Doppler.
Pattern in Peripheral Veins display a negative velocity
Normal blood flow in the
This novel POCUS application enhances the classical (flow away from the trans-
central veins, including the physical examimation in patients with heart failure and ducer) while retrograde
hepatic veins (HVs), is pulsa- provides useful information in addition to that conveyed waves display a positive ve-
tile in nature. This pulsatility by inferior vena cava and lung ultrasound. locity (flow toward the
reflects the normal changes transducer). The normal an-
in RAP that occur with each tegrade waves are the “S”
cardiac cycle.25 Because of the very distensible lumen of and “D” waves and occur during the “x” and “y” descents
normal veins, blood flow pulsatility becomes attenuated of CVP waveform, respectively; In normal subjects, “S”
within veins located farther away from the right atrium re- has a larger amplitude than “D”. The retrograde waves
sulting in a continuous flow (Fig 1A).26 Similarly, normal “A” and “V” correspond to the “a” and “v” waves on
venous blood flow in the portal vein and the renal interlo- CVP waveform.33
bar veins is continuous or nonpulsatile (Fig 1B). When Pathological alterations in right heart filling pattern
venous congestion is present, increased RAP and can alter the HV waveform (Fig 3B). As RAP in-
decreased venous wall distensibility augments the trans- creases, the pressure gradient between the HVs and
mission of pressure causing blood flow to become pulsatile the RA decreases, thus lowering the forward systolic
in distal veins (Fig 1C).27,28 This is also the case for organ flow.34 RV systolic dysfunction or tricuspid regurgita-
venous blood flow. Quantification of these flow alterations tion can also result in decreased “S” wave amplitude
forms the basis of the POCUS assessment of venous or even “S” wave reversal in severe regurgitation. In
congestion.23 addition, increased atrial volume with decreased
compliance will produce large “A” and “V” waves
Performing Doppler Evaluation of Organ Venous typically seen in chronic pulmonary hypertension.35
Flow Velocities Decreased “D” wave amplitude can be seen with
For hepatic and portal vein Doppler, the patient is posi- altered RV relaxation.36 Although a comprehensive
tioned supine or in the left lateral decubitus position. description of every pathological alteration is beyond
Either a curvilinear or phased array probe can be used the scope of this review, a key point is that while
(2.5-5 MHz) which should be positioned in the mid to pos- abnormal HV waveform can clearly identify altered
terior axillary line to identify the liver vessels.29 The probe right heart filling patterns, given the multiple

Adv Chronic Kidney Dis. 2021;28(3):252-261

254 Argaiz

Table 1. POCUS Assessment of Congestive Heart Failure

Evaluates Left-Sided Evaluates Right-Sided Evaluates Transmission of RAP to the
POCUS Parameter Congestion Congestion Organs
Jugular vein ultrasound No Yes No
Lung ultrasound Yes No No
IVC ultrasound No Yes No
Portal and intrarenal venous No Yes Yes
Doppler

Abbreviations: POCUS, point-of-care ultrasound; RAP, right atrial pressure.

Figure 1. (A) Venous Doppler of the hepatic, femoral, and popliteal veins in a healthy subject. Hepatic vein displays a pulsatile
flow while popliteal venous flow is continuous or nonpulsatile. (B) Venous Doppler of the hepatic vein (HV), renal vein (RV),
intrarenal vein (interlobar) (IRV), and portal vein (PV) in a healthy subject. Note that normal intrarenal and portal flow displays
minimal or no pulsatility. (C) Graphical representation of the change in venous volume as a function of increased venous pres-
sure; In venous congestion, there is increased backward pressure transmission secondary to lower venous wall distensibility.

Figure 2. (A) Hepatic and portal vein 2D image acquisition: The probe is placed at the mid-axillary line with the marker
directed toward the patient’s head. Posteriorly, the spinal column is observed (S). A tilting motion directed anteriorly will
reveal the hepatic vein (HV) and then the portal vein (PV). The portal vein has a distinctive echogenic wall. (B) The kidney
can be found posterior and caudal to the liver.

Adv Chronic Kidney Dis. 2021;28(3):252-261

 Assessment of Congestion Using POCUS 255

Figure 3. (A) Normal hepatic vein flow waveform mirrors changes in CVP (see text). (B) Examples of common alterations in
hepatic venous flow.

determinants of the waveform, its usefulness in esti-
mating RAP is suboptimal.37
Portal Vein Doppler Interpretation
The portal circulation is relatively isolated from RAP trans-
mission by the resistance to flow exerted by sinusoidal
capillary vessels.38 Thus, normal blood flow in the portal
vein is continuous or only mildly pulsatile39 (Fig 4A).
Increasing RAP causes a gradual passive distension of si-
nusoidal vessels resulting in a nonlinear fall in resistance.40
In the presence of venous congestion RAP is increasingly
transmitted to the portal vein and flow becomes pulsatile29
(Fig 4B). Portal venous flow alterations occurring in
venous congestion can be quantified using the pulsatility
fraction (PF): PF ¼ 100 * [(Vmax-Vmin)/Vmax]. A
PF , 30% is considered normal, a PF $ 30% but , 50%
is considered moderate, whereas a PF $ 50% is considered
a severe alteration29 (Fig 4A).
Several studies have shown a direct correlation between
increased RAP and portal flow pulsatility.41,42 This finding
was described for the first time in patients with severe
tricuspid regurgitation43; however, it has now been linked
to increased right atrial and pulmonary artery systolic
pressures,29 higher natriuretic peptides, positive fluid bal-
ance,44 and has been consistently associated with RV
dysfunction.44-47
Clinical Studies of Portal Vein Doppler in Heart Failure
One of the first studies linking increased portal vein pulsa-
tility to adverse kidney outcomes was conducted by the
group of Andr
e Denault in Montreal.48 This study
involving patients undergoing cardiac surgery showed

Figure 4. (A) Normal portal vein flow waveform and alterations occurring with venous congestion. (B) Altered portal venous
flow in a venous congestion. Right: Patient with chronic pulmonary hypertension, note hepatic vein displays giant “A” waves.
Left: Patient with severe tricuspid regurgitation, notice reverse “S” wave. Given altered portal flow is secondary to backward
pressure transmission, portal vein flow mirrors hepatic vein morphology.

Adv Chronic Kidney Dis. 2021;28(3):252-261

256
Figure 5. (A) Normal intrarenal venous flow waveform and alterations occurring with venous congestion. (B) Quantification
of intrarenal venous flow using the renal venous stasis index. Higher RVSI values are observed with worsening degrees of
venous congestion.
that a portal vein PF . 50% was independently associated
with an increased risk for the development of AKI (OR,
4.88; CI, 1.54-15.47; P ¼ 0.007). A follow-up prospective
study by the same group confirmed this finding.29 In this
study, alterations in portal vein and intrarenal vein flow
were concordant with each other and were independent
predictors of subsequent AKI development. Further
studies in cardiac surgery patients have also linked
pulsatile portal flow with a higher rate of surgical compli-
cations44 and the development of congestive encephalopa-
thy and delirium.49
In hospitalized patients with decompensated heart fail-
ure, increased portal vein PF was associated with the
development of congestive hepatopathy,50 intestinal
edema,51 and has been proposed as a novel prognostic
tool for heart failure rehospitalizations.52 In a recent pro-
spective study of patients with ADHF, increased portal
vein PF at discharge was closely associated with RV
dysfunction and correlated with increased risk of mor-
tality. However, the predictive value of altered portal
flow was not superior to that of a clinical score of
congestion.46
Intrarenal Vein Doppler Interpretation
Normal intrarenal venous (IRV) flow is continuous or
slightly pulsatile (Fig 1B).53 Because interlobar arteries
and veins run parallel to each other, both vessels are
frequently sampled at the same time and display opposite
flow directions. As RAP increases, progressive alterations
in intrarenal venous flow appear.23 These alterations are
characterized by a discontinuous biphasic pattern in mod-
erate congestion and a monophasic pattern in severe
Argaiz
congestion (Fig 5A). These alterations can also be quanti-
fied using an index of venous flow time to cardiac cycle
time called the renal venous stasis index54 (Fig 5B).
Notably, intrarenal flow alterations have been shown to
be mainly determined by increased RAP and not by car-
diac output in patients with ADHF.5 In an elegant physio-
logic study, experimental volume overload worsened the
IRV flow pattern and increased diuretic resistance in
patients with CHF supporting the role of IRV flow as a
marker of renal congestion.55
Clinical Studies of Intrarenal Venous Doppler in Heart
Failure
In a landmark study by Iida and colleagues, alterations
in IRV flow were strongly correlated with adverse out-
comes including hospitalization and death from cardio-
vascular disease in patients with heart failure.5 IRV
flow alterations were better at predicting the primary
outcome than any other variable. This was true for
both the biphasic (HR, 8.23; CI, 3.45-19.7; P , 0.001)
and monophasic (HR, 23.1; CI, 10.0-53.5; P , 0.001) pat-
terns. Of the 224 enrolled patients, 7 (3.1%) were
excluded because Doppler examination was technically
challenging. Interestingly, this correlation was indepen-
dent of RAP suggesting that pressure transmission to
the organs is an important determinant of adverse out-
comes in this patient population. These results have
been replicated by a similar study.56 In addition, IRV
flow abnormalities quantified by the Renal Venous Stasis
Index (RVSI) were shown to correlate with adverse out-
comes in patients with pulmonary hypertension and
right heart failure.54
Adv Chronic Kidney Dis. 2021;28(3):252-261
 Assessment of Congestion Using POCUS 257

Table 2. VExUS Score

VExUS Score POCUS Assessment
Grade 0 Nonplethoric IVC*
Grade 1 Plethoric IVC with normal or
mild Doppler patterns
Grade 2 (mild congestion) Plethoric IVC 1 severe flow
abnormalities in at least one
Doppler pattern
Grade 3 (moderate Plethoric IVC 1 severe flow
congestion) abnormalities in multiple
Doppler patterns

Mild Abnormality Severe Abnormality

Hepatic vein Doppler “S” wave amplitude lower than Reverse “S” wave
“D” wave amplitude
Portal vein Doppler Pulsatility fraction .30% Pulsatility fraction .50%
Intrarenal vein Doppler Biphasic pattern Monophasic pattern

Abbreviations: POCUS, point-of-care ultrasound; IVC, inferior vena cava; VExUS, Venous Excess Ultrasound Score.
*Plethoric IVC ¼ IVC with a diameter greater than 2 cm and less than 20% inspiratory collapse.

Caveats With Portal and Intrarenal Venous Doppler
and the Purpose of Multiorgan Assessment: Venous
Excess Ultrasound Score Score
Although it has been well established that increased portal
vein PF is a marker of venous congestion and RV failure,
there are several caveats that limit its interpretation as a
single parameter. Increased portal vein PF, even greater
than 50%, has been described in thin healthy subjects
without venous congestion.57 In addition, a case series of
patients with chronic liver disease and normal echocardio-
gram found several patients with increased portal vein
PF.58 These alterations were related to the presence of
arterial-portal shunts and not to elevated RAP.58,59 Thus,
in thin healthy subjects and in patients with chronic liver
disease, increased portal vein PF should be interpreted
with caution. Conversely, falsely normal (nonpulsatile)
portal venous flow has been described in patients with
liver cirrhosis, even in the setting of CHF and severe
tricuspid regurgitation.60 Presumably, the stiff liver paren-
chyma leads to increase sinusoidal resistance and damp-
ening of pressure transmission. Supporting this,
decreased portal vein PF has also been described in pa-
tients with nonalcoholic fatty liver disease.61 Intrarenal
venous Doppler also has important caveats. Compared
with portal vein Doppler, IRV Doppler is technically chal-
lenging and more time consuming.29 Waveform acquisi-
tion is greatly affected by obesity and severe dyspnea.32
In addition, urinary tract obstruction, which increases in-
traparenchymal pressure, can alter IRV flow.62
Given above limitations, it is important to recognize that
no single parameter should be interpreted in isolation.
Multiorgan evaluation should be encouraged to minimize

Figure 6. POCUS evaluation of venous congestion in a patient with myocarditis and heart failure. Apical 4 chamber (A4Ch)
view of the heart shows severe tricuspid regurgitation. Inferior vena cava (IVC) has a diameter of 2.3 cm and showed no res-
piratory variation. Hepatic vein (HV) Doppler shows “S” wave reversal. Portal vein (PV) Doppler shows increased pulsatility
fraction (52%). Intrarenal venous (IRV) Doppler shows a monophasic pattern. VExUS score is grade 3. Abbreviations: POCUS,
point-of-care ultrasound; VExUS, Venous Excess Ultrasound Score.

Adv Chronic Kidney Dis. 2021;28(3):252-261

258 Argaiz

Figure 7. POCUS evaluation of venous congestion in a patient with tamponade physiology. Asterisks show pericardial effu-
sion on echocardiogram. Evaluation before surgical treatment (Right): Hepatic vein (HV) shows “D” wave reversal. Portal vein
(PV) Doppler shows 49% pulsatility. Intrarenal venous (IRV) Doppler shows a monophasic pattern. Evaluation after surgical
treatment (left) shows normalization of venous flow patterns. Abbreviations: POCUS, point-of-care ultrasound.

erroneous interpretation. For example, finding increased
portal vein PF in a thin and healthy subject can be disre-
garded as a false positive by observing a normal sized
IVC with a normal collapsibility index. Recently, a score
involving multiorgan assessment of venous congestion
has been proposed.63 The Venous Excess Ultrasound Score
(VExUS) involves the systematic evaluation of the IVC, he-
patic, portal, and intrarenal venous Doppler flow patterns
as a grading system for venous congestion (Table 2). In a
recent validation study, authors performed a post hoc
analysis of a single-center prospective study involving
145 patients undergoing cardiac surgery. This score pro-
vided higher specificity than any of its individual compo-
nents and offered a useful likelihood ratio (1LR: 6.37; CI,
2.19–18.50) for the prediction of subsequent development
of AKI.22 An example of a complete evaluation of venous
congestion using the VExUS score in a patient with
myocarditis and heart failure is shown on Fig 6.
Improvement of Venous Flow Alterations With
Decongestive Treatment
Organ venous flow alterations can improve after therapies
directed at relieving venous congestion.64 In a recent case
series of patients with ADHF and type 1 cardiorenal syn-
drome presenting to the ED, we showed that diuretic treat-
ment resulted in complete resolution of portal flow
abnormalities and this coincided with return to baseline
of serum creatinine. In patients with right-sided heart fail-
ure, diuretic treatment normalized portal flow alterations;
however, IVC remained plethoric.65 A prospective study
of patients with ADHF showed that severe alterations por-
tal and intrarenal venous flow were highly prevalent at
admission (65% and 59%, respectively) but were largely
reversible after decongestive therapy.45 In a recent series
of patients presenting to the emergency department with
ADHF and cardiorenal syndrome, improvement in
VExUS score correlated significantly with negative fluid
balance and AKI resolution.66 Although in many instances
the treatment of congestion involves diuretic treatment,
venous congestion can result from volume misdistribution
without increased extracellular volume. In this setting,
treatment goals should focus on obstruction relief,
increasing venous capacitance, and afterload reduction.13
An example of improving venous flow alterations after
pericardial window surgery in a patient with tamponade
physiology is shown in Fig 7.
Back to the Case
Hemodynamic AKI was suspected based on evidence of
preserved tubular function. Physical examination and
POCUS of the IVC was consistent with increased RAP.
However, it is important to realize that patients with RV
dysfunction often rely on a higher RAP to maintain
adequate cardiac output.67,68 In addition, tricuspid regur-
gitation might hinder accurate estimation of RAP using
JVP examination.68 Attempting to normalize the IVC or
altered JVP in this patient population might be
detrimental.9,69
Further evaluation of venous congestion was performed
revealing severe alterations in venous flow: HV Doppler
displayed “S” wave reversal and portal vein PF was
.100% (Fig 8A). Although renal Doppler could not be ob-
tained, these findings suggested renal congestion as a
cause of acute kidney injury. The patient was admitted to
the hospital and treated with intravenous diuretics. The
patient maintained adequate urine output and eventually
a negative fluid balance of 14 L was achieved. Repeat
POCUS examination before discharge revealed persistent
alterations on the IVC and HV flow. However, important
improvement in portal flow (PF 15%) was noted (Fig 8B).
Serum creatinine returned to baseline.
Future Directions and Conclusions
Although most clinical studies of altered venous flow have
been conducted in a population of patients with known
cardiac disease, a recent study involving 114 patients con-
ducted in a general ICU cohort showed a significant asso-
ciation between venous flow abnormalities (hepatic and
portal) and major adverse kidney events.70 Given clinical
heterogeneity, a multitude of other factors, besides venous
congestion, contribute to major adverse kidney events in
this population. However, these results suggest that

Adv Chronic Kidney Dis. 2021;28(3):252-261

 Assessment of Congestion Using POCUS 259

Figure 8. (A) POCUS evaluation of the presented case: Inferior vena cava (IVC) displays a diameter of 2.7 cm. Lung ultrasound
(LUS) shows a normal A profile. Apical 4 chamber (A4Ch) view of the heart shows dilated right atrium (**) and right ventricle
(*). Hepatic vein (HV) Doppler shows “S” wave reversal. Portal vein (PV) Doppler shows .100% pulsatility. (B) Improvement in
portal vein pulsatility fraction to 14% after diuretic treatment. IVC and hepatic vein flow alterations did not improve.
Abbreviations: POCUS, point-of-care ultrasound.

venous Doppler might have important implications in
identifying critically ill patients with venous congestion
in whom fluid resuscitation should be limited. Further
studies in this patient population might help fine tune
resuscitation efforts in critically ill patients with venous
congestion.
Doppler analysis of venous flow is emerging as novel
bedside technique that allows the assessment and grading
of venous congestion and is hemodynamic repercussions
at the organ level. Given the increasing spread of POCUS
applications across medical specialties, this tool has the po-
tential to be introduced into clinical practice with relative
ease. Although the use of venous Doppler can definitely
enhance the clinical detection of significant venous conges-
tion, it is not known whether treatment specifically tar-
geted to improve venous flow alterations (diuretics,
inotropic drugs, pulmonary vasodilators) will result in
improved patient outcomes and interventional trials are
needed to investigate this possibility. Studies targeting a
population of patients with severe heart failure and
congestive nephropathy in both the emergency depart-
ment and critical care settings would probably show the
highest yield as effective decongestion often results in
improved renal function.71
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