UNVEXING

THE VEXUS Presenter:

Ezreeah

SCORE
Background
■ The arterial side of circulation has historically received more attention in medical research and
practice.
■ The venous side of circulation, often overshadowed, may be equally critical, and its physiological
impact on organ function is more significant than commonly believed.
■ The true perfusion pressure of an organ is not simply mean arterial pressure (MAP) - central venous
pressure (CVP), but rather precapillary arteriolar pressure minus postcapillary venular pressure.
■ In the capillary beds where arterial pressures are actually very low, CVP becomes a really important
force for organ perfusion.
■ Important to recognise that venous congestion is critical for organ perfusions and almost every
organ in the body can be negatively affected by venous congestion by excess fluid and fluid
overload.
■ Eg: Pulmonary oedema. But this can also affect the whole body. Where else?
Venous congestion assessment
• Available: CVP monitoring, pulmonary artery catheterization via Swanz-Ganz catheter
(not readily available), IVC measurement, portal vein pulsatility index (PI), lung
ultrasound
• Commonest tool: IVC measurement. Poses some challenges.
• IVC size increases proportionally to CVP until it reaches its maximum dilation. Pressure
is then transmitted in a retrograde fashion through the veins to the abdominal organs.
• Dilated IVC may be present in conditions like valvulopathies, pulmonary hypertension,
or even in healthy individuals (e.g., athletes). Has only moderate sensitivity and
specificity, especially in patients with chronically elevated right heart filling pressure or
undergoing positive pressure ventilation.
• Also does not provide information about venous congestion in other vital organs such as
the lungs, liver, gut, and kidneys.
Vexus
■ The Venous Excess
Ultrasonography Score (VExUS) is
a 4-step protocol that evaluates the
presence of congestion in the IVC
and also three target organs: the
liver, the gut and the kidneys.
■ Introduced by William Beaubien-
Souligny et al. (2020). They investigated the performance of different
venous congestion grading systems based on
■ They built on the notion that intra- ultrasound markers to predict AKI after cardiac
abdominal vessels so in particular surgery.
the hepatic vein, the portal vein
and the intra renal veins, all have
predictable Doppler waveforms, and
these waveforms will predictably
change with increasing congestion.
Organs to Evaluate Using
the VExUS Ultrasound
Score Protocol
■ Below are the organs you will be
evaluating using the VExUS
Ultrasound Protocol. As you can see,
you can get a glimpse of venous
congestion from several points prior to
blood entering the right heart.
1. Inferior Vena Cava
2. Liver (hepatic veins)
3. Gut (portal veins)
4. Kidneys (intrarenal veins)
How to perform?
■ Machine Preparation
• Ideally, place the machine on the patient’s right side so you can scan with your right hand and manipulate
ultrasound buttons with your left hand.
• Transducer: Ideally use a curvilinear probe since it can give better resolution of the vessels, but a phased array
probe can be used as well
• Preset: Abdominal
• The Indicator should be on the left side of the screen
• You must have Pulse Wave Doppler capability on your ultrasound system. Most cart-based systems have this.
Unfortunately, most hand-held ultrasounds don’t have Pulse Wave Doppler.

■ Patient Preparation
• Head of the bed should be down
• The patient should be supine
• Have patient bend legs relax the abdominal area to facilitate scanning
View acquisition; IVC
Interpretation:
If the diameter is < 2 cm, there is
no congestion. The VExUS
score is 0, and you do not
need to proceed further.

If the diameter is > 2 cm,

congestion is present. Go to
Step 2
View Acquisition; Hepatic Vein
Steps:
1. Get a 2-D image of the IVC
and hepatic veins.
2. Place colour flow Doppler
over the hepatic veins as they
enter the IVC. You should see
BLUE flow (away from
probe)
3. Place your pulse wave
Doppler gate on a hepatic
vein prior to it entering the
IVC
4. Initiate Pulse wave Doppler
Interpretation
■ The normal flow pattern
closely resembles a CVP
tracing with three waves: a
small retrograde A wave,
followed by anterograde S
and D waves.
■ Mild congestion: D>S
■ Severe congestion: Reversed
S wave (blood flow away
from the IVC, and forward
flow will only occur as the
ventricle relaxes and fills
during diastole)
** In tricuspid regurgitation,
hepatic flow may not be reliable
View acquisition: Portal vein
Steps:
1. Locate portal veins in B-mode
by placing the probe in the right
upper quadrant along the mid-
axillary line and fanning anteriorly
and posteriorly.
2. Identify portal veins by
observing thick and hyperechoic
walls in B-mode.
3. Place colour flow Doppler over
the Right Portal Vein. You should
see RED flow (towards the probe)
4. Place your pulse wave Doppler
gate on the Right Portal Vein
5. Initiate Pulse wave Doppler
 Interpretation
■ Between the GI tract and the
liver, the portal system should
have constant monophasic flow
with minimal variation.
■ As venous congestion increases
and pressure from the hepatic
veins is transmitted across the
hepatocytes into the portal
system, the flow becomes
pulsatile.
■ <30% is normal;
■ 30%- 49% mild portal vein
Pulsatility Index = (Vmax – Vmin)/Vmax. abnormality
■ > 50% severe portal vein
V- max = distance between the baseline and the peak of the wave V- abnormality.
min = distance between the baseline and the trough of the wave
View acquisition; Intra-renal veins
Steps:
1. Locate kidneys at either side in
B-mode at the posterior axillary
line
2. Turn on the colour Doppler
and then look for the Interlobar
vessels (or vessels in the renal
cortex or corticomedullary
junction)
3. Place the pulse wave Doppler
gate
4. Activate pulse wave Doppler.
** The vessels are so small that
you will be able to detect BOTH
the arterial and venous flow. For
VEXUS exam, we focus on the
venous component (bottom
portion of tracing)
Interpretation
■ The Intrarenal vein Doppler
pattern is usually a nice
continuous monophasic flow.
■ Mild congestion: decrease in
the systolic component of the
wave with progression to
biphasic (systolic/diastolic
phases)
■ Severe congestion: complete
absence of systolic flow
showing only monophasic
flow (only diastolic phase).
** The difficulty in visualizing the
renal vessels might preclude the
successful performance of this
step.
Examples…
The VExUS Score – Putting Everything Together

• Grade 0: IVC <2cm = NO Congestion

• Grade 1: IVC >2cm with any combo of Normal or Mildly Abnormal Patterns = MILD
Congestion
• Grade 2: IVC >2cm and ONE severely Abnormal Pattern = MODERATE Congestion
• Grade 3: IVC >2cm and >2 Severely Abnormal Patterns = SEVERE Congestion
■ Beaubien-Souligny, et. al validated the VExUS grading system in a study that analyzed
the risk of acute kidney injury in post-operative cardiothoracic surgery patients.
■ In this system, a higher VExUS grade correlated with a higher risk of acute kidney
injury.
■ VExUS Grade 3 outperformed traditional CVP measurement in the prediction of AKI in
this patient population.
■ This study suggests that damage to the kidney could result from venous congestion
caused by overhydration instead of by hypo-perfusion.
Utilizing the score
■ Assess patient’s intravascular status
■ Guide fluid management decisions- diuretic administration, ascites drainage,
haemofiltration, dialysis, etc.
■ Facilitate adjustments to the current treatment strategy,
■ Avoid complications such as pulmonary oedema and AKI
EVIDENC
E
Pitfalls and caveats
• IVC component:
- valvulopathies, pulmonary hypertension, athletes, chronically Increased intra-abdominal pressure ,
chronic pulmonary hypertension, IPPV.
• Hepatic vein:
- May not show significant changes even in severe tricuspid regurgitation if the right atrium can still
expand and contract normally.
- Interpretation without ECG can be tricky. (S wave? D wave?)
- Underlying liver disease
• Portal vein:
- In thin healthy people, presence of arteriovenous malformations, the portal vein can have a pulsatile
flow without venous congestion.
• Intra-renal:
- Underlying renal disease venous doppler recordings may be less reliable.
• Respiratory translation can make interpretation challenging especially as the targets are very small.
Suggest patient to hold breath in expiration.
• Outside of physiologic factors, another limitation is the need for adequate training and familiarity in
performing and interpreting the technique.
• Risk of variability in technique and interpretation. Consider repeat tracings to ensure consistency of
results and to consider findings within the overall clinical context of the patient.
Bottom line…
■ Even though the protocol estimates volume status well, the score does not specifically
identify the source of venous congestion.
■ It has been recommended that the VExUS score should not be used exclusively, but
rather as an adjunct.
■ The VExUS score is a powerful tool should be strongly considered for the assessment
and management of fluid status in our patients.
■ With its straightforward approach and ease of use, this score is one of the most
promising new techniques for the non-invasive assessment of volume status.
■ The evidence supporting the association between VExUS scores and clinically
significant venous congestion is generally strong, with multiple studies providing
consistent findings.
References
■ Beaubien-Souligny, W., Rola, P., Haycock, K. et al. Quantifying systemic congestion
with Point-Of-Care ultrasound: development of the venous excess ultrasound grading
system. Ultrasound J 12, 16 (2020). https://doi.org/10.1186/s13089-020-00163-w
■ Dinh V. POCUS101 Vexus ultrasound score–fluid overload and venous congestion
assessment.
■ Weingart, S., &; Rola, P. (2016). EMCrit podcast 263 – the VENOUS side – Part 1 –
VEXUS score with Phillipe Rola – emcrit podcast – critical care and resuscitation.
Retrieved April 05, 2021.
■ Webinar: An Introduction to Vexus.
https://www.youtube.com/watch?v=9sAy7_y3sz4&ab_channel=Sonosite