What is VExUS in Point-of-Care Ultrasound
VExUS (Venous Excess Ultrasound) is a standardized point-of-care ultrasound protocol that quantifies systemic venous congestion by integrating assessment of the inferior vena cava (IVC) with Doppler flow patterns of the hepatic vein, portal vein, and intrarenal veins. 1, 2
Core Components of VExUS
The VExUS examination systematically evaluates four key venous structures to grade the severity of venous congestion 2, 3:
- Inferior Vena Cava (IVC): Measures IVC diameter to assess central venous pressure and volume status 2
- Hepatic Vein (HV): Doppler assessment reveals flow patterns that change with increasing venous congestion 2, 3
- Portal Vein (PV): Doppler evaluation detects pulsatility that develops with elevated right atrial pressure 2, 3
- Intrarenal Veins: Doppler patterns show characteristic changes reflecting renal venous congestion 2, 3
VExUS Grading System
The protocol uses a structured grading system to stratify congestion severity 2, 4:
- Grade 0: No venous congestion detected across all measured parameters 4
- Grade 1: Mild venous congestion with abnormalities in one venous bed 4
- Grade 2: Moderate venous congestion with abnormalities in two venous beds 4
- Grade 3: Severe venous congestion with abnormalities across all three Doppler-assessed venous beds 4
Clinical Applications
VExUS provides real-time hemodynamic insights that can guide therapeutic interventions 2:
- Fluid Management: Monitors response to diuretic therapy and guides decongestive strategies in heart failure patients 1
- Perioperative Assessment: Tracks fluid status changes during and after noncardiac surgery, with studies showing 44-49% of patients develop postoperative venous congestion 4
- Dialysis Monitoring: Tracks dynamic changes in volume status during hemodialysis sessions, though the incidence of elevated VExUS scores in dialysis patients is relatively low (15%) 5
Technical Considerations
Achieving proficiency requires comprehensive understanding of Doppler techniques 2:
- Equipment: Requires ultrasound machine with Doppler capabilities and appropriate transducers for abdominal and renal imaging 2
- Success Rate: Studies demonstrate 91% success rate in obtaining all required windows across various clinical settings 4
- Interpretation: Accurate assessment depends on proper machine settings, patient positioning, and recognition of normal versus pathological Doppler waveforms 2
Important Clinical Context
VExUS may reflect cardiac dysfunction rather than purely venous volume status, as patients with elevated VExUS scores often demonstrate both right and left ventricular systolic impairment 5. This distinction is critical because venous congestion can result from heart failure and organ malperfusion even in the absence of absolute volume overload 3.
The technique is particularly valuable because recognizing venous congestion through traditional physical examination or laboratory tests alone can be challenging 2. VExUS provides objective, reproducible measurements that complement clinical assessment and can detect subclinical congestion before overt symptoms develop 2, 3.