Extended venous excess ultrasound: A promising addition to point-of-care ultrasound-based venous congestion assessment

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.

Key Words: Point of care ultrasound; Ultrasound; Venous excess ultrasound; Congestion; Fluid overload; Right atrial pressure; Doppler; Heart failure

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.

INTRODUCTION

We now have ample evidence that fluid overload and hemodynamic congestion contribute to organ injury and increased mortality across various patient populations, not just those with acute heart failure[1-5]. This growing body of data has challenged the traditional approach to managing acute kidney injury (AKI), which has largely relied on empiric fluid therapy[6-10]. The clinical dilemma often resembles the parable of the “blind men and the elephant”, where each individual touches a different part of the animal and forms a distinct conclusion based on limited perspective[11]. In the context of AKI, “blindfolded” clinicians may rely on isolated clinical findings such as hypotension, low fractional excretion of sodium, clear lung sounds, elevated lactate, documented negative fluid balance, or simply the presence of AKI itself, prompting “reflexive” administration of intravenous fluids. This pattern is understandable, and the term blindfolded is not intended as a criticism but rather reflects the historical lack of reliable bedside tools to assess hemodynamic status accurately. Unfortunately, physical examination has low sensitivity for detecting congestion. For example, in a systematic review of 22 studies, the only physical sign with a meaningful positive likelihood ratio for heart failure was the presence of an S3 gallop, which had a sensitivity of just 0.13[12]. Among intensive care unit patients, volume assessment by physical exam showed poor interobserver agreement and failed to correlate with central venous pressure or global end-diastolic volume index[13]. Other metrics, such as intake and output data or body weight, are also prone to inaccuracies[14,15]. Inferior vena cava (IVC) ultrasound gained popularity due to its perceived simplicity, although most early research centered on its role in assessing fluid responsiveness rather than evaluating congestion. Physiologically, using IVC ultrasound to assess congestion is more intuitive, as it reflects right-sided pressures and serves as a surrogate for central venous pressure. However, similar to central venous pressure as a single static measure, IVC ultrasound was eventually found to be unreliable for evaluating fluid responsiveness, which led to a decline in clinical enthusiasm surrounding its use[16,17].

In 2020, Beaubien-Souligny et al[18] introduced the venous excess ultrasound (VExUS) grading system, which integrates IVC ultrasound with Doppler evaluation of the hepatic, portal, and intrarenal veins to quantify systemic venous congestion. This represented a major step forward, allowing clinicians to directly “visualize” congestion at the bedside. VExUS has been shown to correlate more strongly with AKI than CVP alone and has been cited in over 500 publications, highlighting the growing demand among clinicians for more reliable and actionable tools to assess congestion at the bedside. In this opinion review, I will briefly discuss the principles of VExUS and introduce the concept of extended VExUS (eVExUS), which may offer additional value in specific clinical settings.

VEXUS

The VExUS grading system classifies venous congestion into four grades based on IVC size and Doppler waveforms of the hepatic, portal, and intrarenal veins (Figure 1). If the IVC is not dilated, no congestion is assumed (grade 0), and further Doppler evaluation is not performed. When the IVC is dilated but none of the waveforms are severely abnormal, defined as systolic (S)-wave reversal in the hepatic vein, greater than 50% pulsatility in the portal vein, or a monophasic pattern in the intrarenal vein, congestion is considered mild (grade 1). A dilated IVC with at least one severely abnormal Doppler waveform indicates moderate congestion (grade 2), while two or more severely abnormal patterns indicate severe congestion (grade 3). Notably, this study included mechanically ventilated patients, which enhances the real-world applicability of the grading system.

Figure 1 Venous excess ultrasound grading system. VExUS: Venous excess ultrasound; IVC: Inferior vena cava; S: Systolic wave; D: Diastolic wave. Figure reused with permission from NephroPOCUS.com. Available from: https://nephropocus.com/2021/10/05/vexus-flash-cards/.

Although an IVC cutoff of 2 cm was used in the original Canadian cohort for research purposes, this threshold should be interpreted with caution in clinical practice. Factors such as baseline IVC dilation in endurance athletes, small IVC due to elevated intra-abdominal pressure despite high right atrial pressure, and naturally smaller IVC diameters in individuals with low body surface area may all influence interpretation. For instance, a study involving Asian patients identified an optimal IVC cutoff of 1.7 cm for elevated right atrial pressure in those with smaller body habitus[19]. Also, in our practice, we ensure visualization of the IVC in both longitudinal and transverse views to avoid artifacts such as the “cylinder effect”[20]. The three veins selected for Doppler interrogation are anatomically and physiologically distinct, each offering unique insight into venous congestion. The hepatic vein lies closest to the right atrium and faithfully reflects right atrial pressure and filling patterns. The portal vein is downstream of the hepatic sinusoids, which buffer the direct transmission of central venous pressure. The intrarenal (interlobar) veins are located within the renal parenchyma, making them a useful marker of parenchymal congestion caused by venous hypertension. As congestion worsens, interstitial edema accumulates within the enclosed space of the renal capsule, creating a tamponade-like effect that can compromise renal perfusion. This phenomenon is not captured when sampling the main renal vein, which lies outside the parenchyma.

VExUS is influenced by both right atrial pressure (used interchangeably with central venous pressure in this manuscript) and the compliance of the right heart-venous system. While it does correlate well with right atrial pressure, as elegantly demonstrated by Longino et al[21], its real strength lies in predicting organ congestion more effectively than right atrial pressure alone. In other words, VExUS adds clinically meaningful information even when pulmonary artery catheter data are available. In nephrology practice, especially, I find that the most valuable application of VExUS is not just in identifying and grading venous congestion, but in its dynamic nature. These Doppler waveforms improve with decongestive therapy, making VExUS a powerful tool for monitoring the effectiveness of management strategies at the bedside. To avoid multiple self-citations, I am referencing a consolidated online resource that compiles several published cases from the nephrology setting, each illustrating this point with links to the original reports[22]. Importantly, this is not limited to anecdotal evidence. A recent study by Abu-Naeima et al[23] showed that improvement in VExUS grade at 72 hours was associated with significant renal recovery (84.6% vs 47.1% for improved vs non-improved VExUS grades) in patients with cardiorenal syndrome. Though VExUS was initially validated in post-cardiac surgery patients, its utility has since been explored across a range of populations, including ambulatory and hospitalized heart failure patients, as well as general intensive care units cohorts, where it has shown associations with both cardiac dysfunction and clinical outcomes[21,24-28].

A common question that arises is whether VExUS remains useful in settings where waveform patterns may be influenced by factors such as high PEEP, chronic pulmonary hypertension, or tricuspid regurgitation. In a recent paper, Rola et al[29] addressed this point nicely, noting that any measure of venous congestion is fundamentally a reflection of organ afterload. VExUS, by design, evaluates the circulation from the perspective of the organ, that is, downstream rather than from a central cardiac viewpoint. The underlying cause of elevated afterload does not change the interpretation[29]. Simply put, organs do not care why they are congested, and the clinical consequences remain regardless. Specifically, regarding tricuspid regurgitation, Argaiz et al[30] demonstrated that portal vein waveform changes can track volume removal in patients with severe TR, offering a useful bedside measure of therapeutic response. Their group also showed that VExUS correlates well with elevated right atrial pressure in patients with pre-capillary pulmonary hypertension, using right heart catheterization as the reference standard[31]. Since its introduction, VExUS has gained momentum as a practical and accessible bedside tool with a growing range of applications. It is increasingly serving as a shared language among nephrologists, cardiologists, internists, and radiologists. It has contributed to a shift in clinical focus from a forward-flow, fluid responsiveness framework toward one centered on fluid tolerance and venous congestion[32].

THE CONCEPT OF eVExUS

Simply put, eVExUS refers to an umbrella concept that encompasses additional sonographic parameters used to assess venous congestion when the original VExUS veins - hepatic, portal, and intrarenal are inaccessible or unreliable. It is important to note that while eVExUS is not a formally validated scoring system, its individual components have been studied previously. As interest in VExUS has grown, more clinicians have incorporated it into their practice. However, Doppler ultrasound is inherently an advanced point-of-care ultrasound (POCUS) skill, and many POCUS users may not be fully comfortable with its nuances. This has led to a number of technical challenges and misinterpretations, especially in the absence of simultaneous electrocardiographic (ECG) gating. We have summarized key technical pitfalls in our recent publication, which may serve as a useful reference for interested readers[33]. Given these challenges, there has been a growing tendency among some clinicians to focus on a single VExUS component that is easier to obtain, while avoiding more technically demanding elements. This often results in the exclusion of the intrarenal and/or hepatic Doppler components, leaving only the portal vein. Consequently, several modified protocols have emerged, particularly those eliminating the intrarenal vein from the assessment[34]. While such streamlined approaches may offer practical advantages in research settings, they risk oversimplifying the method in clinical practice. The true strength of VExUS lies in the integration of multiple waveforms, where limitations in one vein can be offset by information from the others. Each vein provides distinct and complementary insights, as mentioned above. In my view, the desire to identify a single “ideal” vein undermines the robustness of the approach and should be avoided except in truly technically prohibitive scenarios.

Additionally, in certain patient populations, the standard VExUS veins may be inherently unreliable. For example, in patients with cirrhosis, the IVC, hepatic, and portal veins may be affected by anatomical and functional changes related to liver disease. Similarly, in those with advanced kidney disease, the impact of interstitial fibrosis on intrarenal venous waveforms is poorly understood. In my experience, biphasic intrarenal waveforms can be seen in patients with advanced chronic kidney disease, although this is not a consistent or universal finding. Hepatic vein waveforms, too, are subject to several confounders. Tricuspid regurgitation and reduced tricuspid annular motion can significantly alter the S-wave, which is influenced by both right ventricular systolic excursion and retrograde flow. Fatty liver disease may also result in a blunted hepatic vein pattern, and it remains unclear whether such changes reliably reflect right atrial pressure. Elevated intra-abdominal pressure may compress the IVC externally, leading to a small diameter and an incorrect assumption of no congestion. In postoperative abdominal surgery patients, the subxiphoid window may be inaccessible altogether. Moreover, access to standard right lateral imaging windows may be limited in patients with trauma, surgical dressings, or restricted mobility. Additionally, some patients have inherently poor abdominal acoustic windows, further complicating image acquisition. In such cases, it is reasonable to expand the evaluation to include additional veins that may offer insights into systemic venous congestion.

The internal jugular vein ultrasound

The internal jugular vein (IJV) has traditionally been used to estimate jugular venous pressure during physical examination, although its sensitivity is limited by the difficulty of visualizing venous pulsations[35]. Given its superficial location and ease of visualization with ultrasound, the IJV POCUS serves as a practical alternative when IVC assessment is not feasible or proves unreliable. Various ultrasound-based techniques have been described to estimate central venous pressure using the IJV. These include measuring the vertical height of the blood column (collapse point of the vein) from the sternal angle and adding an assumed right atrial depth of 5 cm, like traditional physical examination. Other approaches involve assessing the aspect ratio of the vein, evaluating its collapsibility or distensibility with respiration, measuring the maximum anteroposterior diameter, measuring changes in cross-sectional area or diameter during the Valsalva maneuver, and combining jugular height with echocardiographic measurement of right atrial depth[36]. Notably, directly measuring right atrial depth using cardiac ultrasound enhances accuracy compared to assuming a fixed value of 5 cm. This method involves first identifying the highest point of jugular venous collapse, often described as resembling a wine bottle or paintbrush, as illustrated in Figure 2. A focused cardiac ultrasound is then used to obtain the parasternal long-axis view, where right atrial depth is measured from the skin surface to the attachment point of the non-coronary cusp of the aortic valve at the posterior left ventricular outflow tract. The jugular column height and the measured right atrial depth are then summed to estimate right atrial pressure in centimeters of water, which can subsequently be converted to millimeters of mercury. This technique has been shown to predict right atrial pressure within 3 mmHg of catheterization-derived values in approximately 74% of cases[37]. Compared to IVC ultrasound, which provides broad estimated ranges of right atrial pressure, the ability to derive a specific value that closely approximates invasive measurements is a particularly appealing feature of this approach. Interestingly, IJV ultrasound has been shown to outperform IVC assessment in patients with cirrhosis and elevated intra-abdominal pressure, supporting its use as a preferred alternative in these clinical settings[38,39].

Figure 2 Long-axis ultrasound of the internal jugular vein demonstrating the collapse or taper point, often compared to a wine bottle or paintbrush. Image reused with permission from NephroPOCUS.com. Available from: https://nephropocus.com/interesting-signs-and-metaphors/.

IJV ultrasound does come with some practical limitations. For instance, the presence of multiple techniques described in the literature, without direct comparative data among them, represents a limitation in itself. Additionally, measurements are susceptible to various external factors such as transducer pressure, head angle and positioning (for example, turning the head to one side can engorge the contralateral IJV and falsely suggest elevated right atrial pressure), variability in the strength of respiratory effort or Valsalva maneuver, and even patient talking during the assessment, all of which can contribute to inaccurate results[36,40]. IJV Doppler is an appealing alternative to hepatic vein Doppler, as the waveform closely mirrors that of central venous pressure. Abnormal patterns, such as an S-wave smaller than diastolic (D)-wave or complete S-wave reversal, reflect venous congestion and altered right heart hemodynamics[41,42]. Figure 3A and B illustrate both normal and severely abnormal IJV Doppler waveforms. IJV Doppler is relatively easy to obtain, but it is sensitive to transducer pressure and requires proper patient positioning. Accurate interpretation relies on simultaneous ECG tracing, although in some instances, an adjacent carotid artery waveform can serve as a surrogate timing reference. Given that the IJV drains cerebral circulation, its assessment may be particularly relevant in cases of suspected congestive encephalopathy (venous congestion-related cognitive dysfunction), either due to elevated right atrial pressure or central venous obstruction, as in hemodialysis patients. Although this application has not been formally studied, the idea is inspired by findings from a study that demonstrated an association between portal vein pulsatility and congestive encephalopathy in post-cardiac surgery patients[43].

Figure 3 Internal jugular and femoral vein Doppler patterns across congestion states. A and B: Doppler waveforms of the internal jugular vein showing a normal pattern (A) and a severely abnormal pattern (B). In the normal waveform, the systolic wave is greater than the diastolic (D) wave. In the abnormal pattern, the systolic wave disappears, leaving only a prominent D-wave below the baseline, indicating flow toward the heart in diastole; C and D: Normal femoral vein Doppler waveform (C) compared with a waveform showing elevated stasis index (D), characterized by prolonged flow gaps during the cardiac cycle, indicated by white double-headed arrows. The femoral vein stasis index is calculated as the percentage of this no-flow interval relative to the duration of the cardiac cycle. In this example, only a diastolic wave is seen below the baseline, with absent systolic flow; E: Another example of an elevated femoral vein stasis index, but with both systolic and D-waves below the baseline. Presumably a less severe pattern than D.

Femoral vein Doppler

Due to its technical simplicity and rapidity, femoral vein Doppler is becoming one of the most popular components of extended venous ultrasound. In normal conditions, femoral vein Doppler flow is typically continuous with respiratory variation or mildly pulsatile, without significant interruptions within a single cardiac cycle. As venous congestion increases, the waveform becomes increasingly pulsatile, often exhibiting flow interruptions, as illustrated in Figure 3C-E. This has also been quantified using the femoral vein stasis index (FVSI), which represents the percentage of the cardiac cycle during which there is no antegrade flow toward the heart. In other words, a higher proportion of flow interruption or reversal corresponds to more severe congestion. Although the association between pulsatile femoral vein flow and right heart failure was described as early as 1984[44], interest in its clinical relevance has been renewed in recent years, particularly following the development of the VExUS grading system and subsequent studies by the original VExUS investigators[45]. In a prospective study of 107 post-cardiac surgery patients, femoral vein Doppler demonstrated an accuracy of 74.7% for detecting venous congestion, slightly lower than the 80.4% accuracy observed with VExUS. Agreement between femoral vein Doppler and VExUS was moderate (κ = 0.62), suggesting reasonable alignment between the two methods. In contrast, agreement between femoral vein Doppler and central venous pressure was weaker (κ = 0.49), underscoring the limitations of central venous pressure as a sole marker of systemic congestion[46]. Because the femoral vein lies farther from the heart, its sensitivity for detecting elevated central venous pressure is logically lower, whereas its specificity remains high. Consistent with this, in a 1996 study, femoral vein Doppler showed a sensitivity of 46% and specificity of 94% for elevated right atrial pressure[47], indicating that although a normal waveform may not exclude congestion, an abnormal one strongly suggests its presence. Notably, a recent retrospective study of 57 patients undergoing right heart catheterization found that FVSI had strong diagnostic accuracy for detecting elevated right atrial pressure (FVSI > 0.27 correlated with RAP ≥ 10 mmHg), particularly in patients with pulmonary hypertension. FVSI outperformed echocardiography-estimated right atrial pressure, showing a diagnostic accuracy of 90.4% and specificity of 92.3%, compared to just 51.2% accuracy of echo-derived right atrial pressure[48]. In case it appears that my statements about Doppler findings and right atrial pressure are inconsistent, let me clarify. Venous Doppler waveforms are influenced not only by right atrial pressure but also by the compliance of the right heart–venous system. So, while the waveforms do logically correlate with right atrial pressure, it is not the sole determinant. Doppler offers a more direct window into organ-level congestion since it accounts for compliance across the system. In fact, in a recent cardiac surgery cohort, femoral vein Doppler pulsatility was associated with a significantly higher incidence of postoperative AKI (35% vs 16%)[49]. Femoral vein Doppler may be particularly useful in situations where hepatic vein waveforms are chronically abnormal, such as in cases of severe tricuspid regurgitation. We previously reported an illustrative case in a patient with end-stage kidney disease and significant tricuspid regurgitation, where femoral vein Doppler improved in parallel with fluid removal, despite persistently abnormal hepatic vein findings[50]. It also serves as a valuable alternative in patients with cirrhosis, where both hepatic and portal vein assessments may be unreliable. However, caution is warranted in patients with known or suspected intra-abdominal hypertension, as elevated intra-abdominal pressure may blunt femoral vein flow and limit its ability to reflect intracardiac hemodynamic changes accurately[51,52]. From a technical standpoint, the use of simultaneous ECG enhances interpretation by helping distinguish true cardiac pulsatility from respiratory variation, which may otherwise be misinterpreted[33]. In addition to qualitative assessment of pulsatility and the use of the FVSI, some studies have also evaluated the absolute velocity of the retrograde component, typically using a cutoff such as > 10 cm/second to define abnormal flow. However, velocity-based measurements can be prone to error, particularly in the hands of less experienced users or when appropriate angle correction is not applied.

SVC Doppler

The superior vena cava (SVC) is directly connected to the right atrium, making it a suitable vessel for assessing right heart hemodynamics and systemic venous congestion. However, because the IJV is more readily accessible, SVC has been less frequently explored for this purpose. Notably, studies dating back to 1987 have shown that the Doppler waveform of the SVC closely resembles that of the hepatic vein, although the reversal components (the A wave from atrial contraction and the V wave representing transition between systole and diastole) are typically less prominent[53]. This difference may be attributed to two factors. First, the SVC is generally sampled from the suprasternal window, whereas the hepatic vein is imaged closer to the right atrium. Second, the intrahepatic location of the hepatic veins may reduce local compliance due to the surrounding hepatic parenchyma, resulting in more pronounced reversal waves. SVC can typically be visualized using suprasternal or supraclavicular windows, as well as the subcostal window in most patients. The subcostal approach offers a view of both IVC and SVC, often referred to as the bicaval view. This is also known as the snail view, where the right atrium resembles the shell and the IVC and SVC represent the head and tail of the snail, respectively. It is obtained by rocking the transducer superiorly from the traditional IVC long-axis view, with gentle rotation as needed (Figure 4A and B). Modified parasternal and apical windows have also been described[54], though in my experience, these are more technically challenging. I typically rely on the supraclavicular or subcostal approach. An interesting study comparing SVC Doppler obtained from both subcostal and supraclavicular windows found that systolic and diastolic flow velocities were consistently higher via the subcostal approach. Importantly, the SVC systolic-to-diastolic (S/D) wave ratio obtained from the subcostal window showed a stronger correlation with right atrial pressure than the supraclavicular approach, likely due to the sampling site’s closer proximity to the right atrium. A subcostal SVC S/D ratio of < 1.9 identified elevated right atrial pressure with 85% sensitivity and 74% specificity. Additionally, combining SVC-S/D with IVC size and collapsibility improved overall diagnostic accuracy[55]. In another study by the same investigator group, the SVC S/D ratio showed a stronger correlation with elevated right atrial pressure than the hepatic vein systolic filling fraction (proportion of systolic flow during the cardiac cycle). This difference may be partly due to the SVC sampling site’s closer proximity to the right atrium, but also to inherent differences between the S/D ratio and filling fraction as distinct Doppler parameters[56]. Ultimately, the evidence is not strong enough to favor one vein or sampling site over another. In real-world point-of-care settings, I turn to SVC Doppler when hepatic vessels are unreliable or as an additional data point in patients with an anatomically favorable subxiphoid window. Figure 4C and D illustrate normal and severely abnormal SVC waveforms.

Figure 4 Superior vena cava Doppler. A and B: Subcostal bicaval view with corresponding illustration; C and D: Panel C shows a normal superior vena cava Doppler waveform obtained from the bicaval view with a systolic wave greater than the diastolic wave. Panel D demonstrates a severely abnormal pattern with systolic wave reversal. The tracing in panel D was obtained from a modified parasternal view, which often results in suboptimal Doppler angle and consequently lower recorded flow velocities. IVC: Inferior vena cava; RA: Right atrium; SVC: Superior vena cava; S: Systolic; D: Diastolic.

Splenic vein Doppler

The splenic vein joins the superior mesenteric vein to form the portal vein, and therefore, its Doppler flow is expected to mirror that of the portal vein. This makes it a useful alternative when the standard right lateral window is inaccessible due to patient positioning, surgical dressings, or other factors. However, in cases of cirrhosis where portal flow no longer reliably reflects central venous pressure, the splenic vein offers limited additional value. Most of the existing literature on splenic vein Doppler focuses on liver disease and gastric varices, with limited exploration of its role in systemic hemodynamics. Only recently has its utility in assessing venous congestion gained attention. In a study of children undergoing congenital heart surgery, Lee et al[57] found that splenic vein pulsatility index improved postoperatively, closely paralleling changes seen in the portal vein. Two case series in adult cardiac surgery patients have also reported improvement in splenic vein Doppler patterns following surgical intervention[58,59]. Figure 5A and B show a normal splenic vein waveform, while Figure 5C and D illustrate strikingly pulsatile portal and splenic vein flows appearing like mirror images that I captured in a patient with cardiorenal syndrome.

Figure 5 Splenic vein Doppler. A and B: Panel A shows the anatomy of the splenic vein, historically labeled as the lineal vein, and its connection to the portal vein. Panel B displays a normal Doppler waveform of the splenic vein; C and D: Severely abnormal portal (C) and splenic vein (D) waveforms resembling mirror images, obtained from a patient with cardiorenal syndrome. Anatomy image A modified from Gray’s Anatomy (public domain image). Available from: https://en.wikipedia.org/wiki/Splenic_vein.

CONCLUSION

While VExUS has provided clinicians with a powerful framework to assess systemic venous congestion, it is essential to recognize that the original components - hepatic, portal, and intrarenal veins are not always accessible or reliable in every clinical scenario. eVExUS offers an expanded set of tools to overcome these limitations, using veins such as the femoral, internal jugular, SVC, and splenic veins. Knowledge of these alternatives is essential in real-world practice where patients present with diverse anatomies, comorbidities, and technical barriers that defy oversimplified protocols. While simplification is often necessary to facilitate learning and adoption, overly rigid or reductionist approaches risk misinterpretation and missed diagnoses. Correlating venous Doppler patterns with right atrial pressure is an important step in clinical validation, but future research should go further by examining how these findings relate to organ dysfunction and meaningful patient outcomes. For example, studies should explore whether improvements in Doppler waveforms correspond with recovery of organ function or a reduction in hospital readmissions. There is also a need to develop tailored protocols for specific conditions such as cirrhosis, pulmonary hypertension, and advanced kidney disease. The more comprehensive our data, the better we can navigate the complex physiology of hemodynamic disorders. Otherwise, as described in the introduction, we remain like the ‘blindfolded clinicians’ drawing conclusions from a single part of the picture rather than seeing the whole.