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Congress: ECR25
Poster Number: C-19930
Type: Poster: EPOS Radiologist (educational)
Authorblock: P. M. A. Da Silva1, F. S. Muñoz1, A. Zakharova2, T. Rebello1, J. Traila Campos1; 1Viana do Castelo/PT, 2Kharkiv/UA
Disclosures:
Pedro Miguel Alves Da Silva: Nothing to disclose
Fabiana Santos Muñoz: Nothing to disclose
Anastasiia Zakharova: Nothing to disclose
Tulio Rebello: Nothing to disclose
José Traila Campos: Nothing to disclose
Keywords: Abdomen, Emergency, Veins / Vena cava, Ultrasound, Diagnostic procedure, Education and training, Haemodynamics / Flow dynamics
Findings and procedure details

The VExUS score is based on the assessment of four distinct vascular structures, providing an estimation of venous pressure in various organs, including the liver, bowel, and kidneys, as illustrated in Figure 1

Fig 1: Illustration of the veins evaluated in the protocol, along with the corresponding organs where venous pressure is estimated.
. When additional intravascular volume due to congestion exceeds the systemic venous capacitance, a rapid rise in venous pressure occurs, leading to vessel dilation and/or abnormal Doppler waveforms. The score is determined by evaluating the inferior vena cava diameter along with the Doppler waveforms of the hepatic, portal, and intrarenal veins. This assessment provides an estimate of venous congestion, guiding clinical decision-making and further management. Simultaneous electrocardiogram (ECG) monitoring aids in identifying the phases of the cardiac cycle, facilitating accurate interpretation of Doppler waveforms.

Based on the Doppler analysis, a score of 0 to 3 is given:

VExUS score 0 – Absence of significant congestion (IVC diameter <2 cm)

VExUS score 1 – Mild congestion (IVC diameter ≥ 2 cm and any combo of normal or mildly abnormal patterns)

VExUS score 2 – Moderate congestion (IVC diameter ≥ 2 cm and one severe abnormal pattern)

VExUS score 3 – Severe congestion (IVC diameter ≥ 2 cm and ≥ two severe abnormal patterns)

The initial vascular structure assessed in the VExUS scoring system is the inferior vena cava (IVC). Measurement of the IVC diameter is widely utilized in point-of-care ultrasound (POCUS) to estimate right atrial venous pressure and assess fluid status. However, this measurement alone does not reliably reflect left ventricular preload. IVC dilation can be observed in healthy individuals, such as athletes, as well as in patients with valvular heart disease or pulmonary hypertension.

In the VExUS score, an IVC diameter of less than 2 cm concludes the assessment, assigning a VExUS score of 0, indicating no significant venous congestion is present. (Figure 2)

Fig 2: Ultrasound longitudinal view of the IVC in a healthy 27-year-old female. The maximum diameter during the respiratory cycle, 2 cm below the point where the hepatic veins drain to the IVC, is 19 mm. No significant venous congestion is observed - VExUS score 0.
Conversely, if the IVC diameter is ≥ 2 cm, further evaluation of the remaining three vascular structures is required to determine the severity of congestion. (Figure 3)
Fig 3: Ultrasound longitudinal view of the IVC in a 92-year-old male patient with heart failure reveals a maximum diameter of 39 mm, measured 2 cm below the confluence of the hepatic veins. This finding indicates significant venous congestion, warranting further assessment of the vascular beds included in the VExUS score.

The authors of this scoring system recommend measuring the IVC in its intrahepatic segment using a sub-xiphoid longitudinal approach, approximately 2 cm distally from the point where the hepatic veins drain to the IVC. However, some literature also suggests measuring the IVC diameter 2 cm distal to the cavoatrial junction as an alternative method for estimating right atrial pressure.

For the evaluation of the hepatic veins, the right and middle hepatic veins are typically more accessible, as bowel and gastric gas can obscure visualization of the left hepatic vein. These vessels can be evaluated using a subxiphoid approach before their entry into the inferior vena cava (IVC) or alternatively via a lateral intercostal approach to assess the right hepatic vein.

In a euvolemic patient, the hepatic vein Doppler waveform consists of a systolic (S) wave followed by a diastolic (D) wave, with the S wave demonstrating equal or greater flow velocity compared to the D wave. (Figure 4)

Fig 4: Ultrasound oblique view of the liver in a 68-year-old female patient. Doppler spectrum at the right hepatic vein shows a systolic (S) wave followed by a diastolic (D) wave, with the S wave demonstrating equal or greater flow velocity compared to the D wave. This is a normal finding.
As venous congestion develops, the S wave becomes less pronounced than the D wave, indicating mild abnormality. (Figure 5)
Fig 5: Ultrasound oblique view of the liver in a 92-year-old male patient with heart failure. Doppler spectrum at the left hepatic vein shows that the S wave becomes less pronounced than the D wave, indicating mild abnormality. The hepatic veins are also visibly enlarged.
With worsening congestion, S wave reversal occurs, appearing above the baseline, which is considered a marker of severe venous congestion. Figure 6 is an illustration depicting the normal, mild and severe abnormalities of the hepatic vein waveform. (Figure 6)
Fig 6: Illustration depicting the normal hepatic vein waveform, along with examples of mild and severe abnormalities.

Portal vein pulsatility has been extensively described in the context of heart failure. Under normal conditions, the portal vein Doppler waveform is monophasic with minimal variation throughout the cardiac cycle. However, as venous congestion worsens, pulsatility progressively increases. Using the peak (Vmax) and nadir (Vmin) velocities, the pulsatility fraction (PF) can be calculated as follows:

PF (%) = 100 x ((Vmax – Vmin)/ Vmax)

A PF below 30% is an expected finding in euvolemic patients. (Figure 7)

Fig 7: Ultrasound oblique view of the liver hilum in a 68-year-old female patient. Doppler spectrum at the portal vein shows continuous flow with minimal variation throughout the cardiac cycle.
A PF of 30-49% indicates a mildly abnormal pattern. (Figure 8)
Fig 8: Ultrasound longitudinal view of the portal vein at the hepatic hilum in a 32-year-old female. Doppler spectrum at the portal vein shows continuous flow with variation throughout the cardiac cycle. Pulsatility fraction of 35%. These findings indicate a mild abnormality of the portal vein waveform.
If PF is equal or greater than 50%, a severely abnormal waveform is present. Figure 9 is an illustration depicting the normal, mild and severe abnormalities of the portal vein waveform. (Figure 9)
Fig 9: Illustration depicting the normal portal vein waveform, along with examples of mild and severe abnormalities. The pulsatility fraction formula is also included.

Lastly, the intrarenal veins, particularly the interlobar veins, should be carefully evaluated. This step can be particularly challenging due to the small caliber of these vessels and, in some cases, the patient's inability to regulate their breathing pattern as instructed by the examiner. While Doppler setting adjustments are always important, they are especially critical for the assessment of interlobar veins to obtain an optimal waveform. Due to the small vessel dimensions at this location, arterial and venous Doppler signals are often detected within the same imaging plane. In the absence of venous congestion, the intrarenal venous Doppler waveform appears continuous and monophasic. (Figure 10)

Fig 10: Ultrasound view of the left kidney in a healthy 27-year-old female. Doppler spectrum at the interlobar veins show normal continuous flow (below baseline). The arterial flow (above baseline) is also detected given the small caliber of these vessels.
A discontinuous, biphasic waveform (comprising systolic and diastolic components) suggests mild intrarenal venous dysfunction. As renal congestion progresses, the systolic wave becomes absent, resulting in a discontinuous monophasic waveform (exhibiting only the diastolic component), which is indicative of severe venous abnormality. (Figure 11)
Fig 11: Ultrasound longitudinal view of the left kidney in a cirrhotic 78-year-old male patient. Doppler spectrum at the interlobar show severe abnormality findings, with a discontinuous monophasic wave corresponding to the diastolic component. A large septated cyst is also observed.
Figure 12 is an illustration depicting the normal, mild and severe abnormalities of the interlobar vein waveform. (Figure 12)
Fig 12: Illustration depicting the normal interlobar renal vein waveform, along with examples of mild and severe abnormalities.
GALLERY