Koratala A. Extended venous excess ultrasound: A promising addition to point-of-care ultrasound-based venous congestion assessment. World J Cardiol 2026; 18(1): 112636 [DOI: 10.4330/wjc.v18.i1.112636]
Corresponding Author of This Article
Abhilash Koratala, Associate Professor, Senior Researcher, Division of Nephrology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Room A 7633, Milwaukee, WI 53226, United States. akoratala@mcw.edu
Research Domain of This Article
Medicine, General & Internal
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Cardiol. Jan 26, 2026; 18(1): 112636 Published online Jan 26, 2026. doi: 10.4330/wjc.v18.i1.112636
Extended venous excess ultrasound: A promising addition to point-of-care ultrasound-based venous congestion assessment
Abhilash Koratala
Abhilash Koratala, Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
Author contributions: The author conceived the review topic, conducted the literature search, analyzed the relevant studies, and drafted and revised the manuscript in its entirety. The author approved the final version for submission and is accountable for all aspects of the work.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Abhilash Koratala, Associate Professor, Senior Researcher, Division of Nephrology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Room A 7633, Milwaukee, WI 53226, United States. akoratala@mcw.edu
Received: August 1, 2025 Revised: August 8, 2025 Accepted: November 12, 2025 Published online: January 26, 2026 Processing time: 167 Days and 4 Hours
Abstract
Systemic congestion is increasingly recognized as a major contributor to organ dysfunction and adverse outcomes in patients with heart failure and in those at risk of fluid overload. The venous excess ultrasound (VExUS) grading system, introduced in 2020, uses Doppler evaluation of the hepatic, portal, and intrarenal veins to quantify venous congestion at the bedside. While abnormal venous waveforms have been recognized for years, the formalization of VExUS has provided a structured and clinically meaningful framework, generating widespread academic interest with over 500 citations to date. This article blends current evidence with the author’s perspective to review the principles, strengths, and limitations of VExUS and to outline the emerging concept of extended VExUS (eVExUS). VExUS has practical limitations when standard windows are inaccessible or unreliable, such as in patients with cirrhosis, advanced kidney disease, or difficult body habitus. The eVExUS approach addresses these challenges by incorporating additional venous Doppler assessments, including the internal jugular, superior vena cava, femoral, and splenic veins, as well as grayscale-based internal jugular measurements to estimate right atrial pressure when inferior vena cava imaging is suboptimal. While eVExUS offers a more adaptable, individualized strategy, its clinical adoption is still in the early stages. Further studies are required to validate eVExUS, link its findings to patient outcomes, and inform the development of tailored imaging protocols for diverse patient populations.
Core Tip: Venous excess ultrasound has advanced bedside assessment of systemic venous congestion, but its standard components are not always accessible or reliable. The concept of extended venous excess ultrasound introduces alternative veins, including the internal jugular, femoral, splenic, and superior vena cava, to overcome these limitations and improve flexibility in real-world settings. Understanding these complementary windows is essential, especially in patients with altered anatomy or comorbidities like cirrhosis. While correlating Doppler findings with right atrial pressure is important, future studies must also link them to clinical outcomes and develop context-specific protocols for broader, safer clinical adoption.
