Today I review, link to and excerpt from MetroHealth Emergency Ultrasound‘s Bedside Assessment of Venous Congestion.
All that follows is from the above resource.
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11:35 PF (pulsatility fraction) refers to the Portal Vein Vmax and Vmin
12:17 Below are Portal Vein Dopplers from individual patients with Acute Kidney Injury. In figure A, the return of the portal vein to normal pulsatility after diuretic treatment corresponded to an IVC (in most patients) with normal inspiratory collapse and return of the serum creatinine to normal.
In figure B, the right graph represents what happens to the IVC after decongestive therapy. In pts with left heart failure, we were able to get a normal IVC nspiratory collapse. “And we did not observe this with right heart failure.” “So the Portal Vein is a much more useful tool than IVC collapsibility in right heart failure.”
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15:43 The bottom doppler shows intraparenchymal flow with arterial flow above the baseline and venous flow below the baseline.
17:o1 The blue line (first doppler) is normal intrarenal flow. The green line (middle doppler) is abnormal biphasic flow. And the red line (bottom doppler) is severely abnormal intrarenal flow.
18:15 The VExUS Score
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20:30 “Here is an actual real life clinical example of how this looks when we perform a complete VExUS score on a patient presenting with cardiorenal syndrome.”
22:22 How To Perform The VExUs Exam.
For the hepatic and portal veins, place the phased array or curvilinear probe with the abdominal presents at the mid-axillary line.
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here you will revealthe liver you’ll see this big hepatic vein and you know perpendicular to it you will see the portal vein you can use color
flow to kind of visualize them better the portal vein has a continuous red color flow and the normal hepatic
vein usually has this pulsatile blue flow on color doppler
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you put the gate inside of the blood vessel and you you ask the patient to hold the breath and then you press the button again andyou will get this you know nice hepatic vein wave form tracing which is composed
you know normally of the s the d wave and the a waves
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you put the gate inside of the blood vessel and you you ask the patient to hold the breath and then you press the button again andyou will get this you know nice hepatic vein wave form tracing which is composed
you know normally of the s the d wave and the a waves
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you can do the same thing for the portalvein now you just set the gate inside of the portal vein and you press the pulse wave doppler button again
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and here yousee this is a normal patient with a normal portal vein waveform just you know a little bit
pulsatile but this is less than 30 volatility which is completely normal in a healthy patient*
*See 11:35 for The Pulsatility Fraction of the Portal Vein:Back to 23:42
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now for evaluating the intra-renal doppler you displace the probe a little bit posteriorly and hereyou will reveal this long axis of the kidney and here is where you perform the exam
but first i would suggest to switch to renal mode because this actually lowers
the color scale to about 16 centimeters per second and this allows
me to see lower velocity flows so here i i’m showing the earlier vessels and if you displace a little bit
posterior you will reveal these intrarenal vessels which are the ones you want to to evaluate
you will reveal this long axis of the kidney and here is where you perform the exam
but first i would suggest to switch to renal mode because this actually lowers
the color scale to about 16 centimeters per second and this allows
me to see lower velocity flows so here i i’m showing the earlier vessels and if you displace a little bit
posterior you will reveal these intrarenal vessels which are the ones you want to to evaluate
posterior you will reveal these intrarenal vessels which are the ones you want to to evaluate
and so here you you select a couple of arteries and veins that look good here
you ask the patient again to hold the breath and you press the pulse wave doppler button and here you have a normal
uh renal waveform with arterial waveform on the top and the normal vehicle
on the bottom and this waveform is you know mainly positive slightly positive but still continuous and non-interrupted
which is considered normal
24:5425:12one of the most frequent questions we get is is it worth it to vectors a patient that has a normal IVC25:25
and the answer is no of course not a patient with a normal ibc is very unlikely to have severe venouscongestion or veins congestion and so you know if you go ahead and do vectors and you find
some alterations it is most likely that they represent false positives rather than than true venous congestion because the
first step the first step in venus congestion is actually a a [evaluation] of IVC so the IVC could be
thought of as a screening tool to detect the presence of venous congestion and
then if you find it then you can use the VExUS exam to further evaluate or
graduate the degree or the severity of this congestion
26:01Yes, this happens all the time.26:07So you know the lung ultrasound that evaluates b-line pattern
mainly assesses left-sided congestion or pulmonary congestion and [so] yes there can be abdominal or
systemic venous congestion without pulmonary congestion. We see this a lot in patients with predominantly
right-sided heart failure or we can also see this in patients with biventricular dysfunction
but that have been chronically adapted and have increased pulmonary lymphatic function [and hence no rales and no b lines on lung POCUS]
26:44 [Above] This is a patient with severe chronic pulmonary hypertension and right ventricular
dysfunction you can see here the design and dilated RV but the left ventricular function is
relatively preserved and so this patient actually had a normal lung ultrasound with an a profile all across the board
and if we look at venus congestion we see this patient had severe venous congestion as evidenced by a
plethoric non-collapsing IVC, [and] an alteration in hepatic vein flow. This is characterized by giant a wave is very
common in pulmonary hypertension and this pressure is being able to to be transmitted
all the way to the portal vein causing increased volatility here at greater than even 60
so this patient has severe venous congestion without pulmonary congestion.
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27:32then how do you interpret vexusin patients that have severe tricuspid regurgitation and you know the same the same way this
27:40[Here] is an example that can be useful. This is a patient with severe pulmonary hypertensionright ventricular dysfunction and severe tricuspid regurgitation and obviously we’re always gonna see
this systolic reversal on the hepatic vein but when i saw this patient, this patient
was not feeling great. Had a lot of shortness of breath and exceptional dyspnea and
when i evaluated the portal vein it showed 100% pulsatility so very compatible with
severe venous congestion. So i decided to treat this patient carefully with diuretics
and you know after treatment patient actually felt much better.
Obviously I did not cure [the] pulmonary hypertension. This patient’s practically palliative
care patient, but you know the patient felt better. We did not cure the tricuspid regulation of course so there’s
persistent reversal of the s wave [of the hepatic vein doppler]. However we were able to normalize
portal venous flow and so you know this this can help you see how the portal
domain can still be useful and can still be used to assess venous congestion even in the presence of severe
tricuspid regurgitation.
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28:53 Can you have a vexus 3
[meaning can] we have severe venous congestion with a normal hepatic vein? and yes this happens all
the time. For example, if the filling pattern of the right heart is normal
then the hepatic vein is gonna be normal right independently of the filling pressures
so you know this is a case i like a lot because this was a patient with a severe heart failure with preserved
ejection fraction so left-sided heart disease who actually did not come to the hospital because of the Covid
pandemic and he waited like a lot of months in his house and he came to the hospital with over 30
kilograms above his usual weight so he was severely volume overloaded severely
it had severe venous congestion as you can see here this is a plethoric non-collapsible IVC and also severe
venous congestion shown by a portal vein positivity fraction of greater than a hundred percent
and a biphasic pattern on the intrarenal venous doppler. However look at the hepatic vein. The
pattern is completely normal normal. s is greater than d wave and and this is because the filling
pattern of the RV in this patient is normal however the filling pressure is definitely increased
so this pressure can be easily transmitted all the way to the portal and the intra-renal veins so we gave this patient a lot of iv
diuretics and after the patient lost about 25 to 30 kilograms of fluid weight, these
alterations in portal and intrarenal veins actually normalized
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Next question: Does VExUS 3 means the patient needs diuretics?
Definitely not. VExUS 3 means the patient has venus congestion and so it’s important
not only to realize that patient has venous congestion but to actually identify the cause. So certainly
volume overload can cause venous congestion in patients with heart failure.This is frequent. However,
not always and some causes of venous condition are not due to volume overload. For example, look at this case. This was a
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patient with severe venous congestion but the cause of this patient’s congestion was actually a tamponade
physiology so look here i am seeing i’m showing the pericardial effusion the diastolic collapse of the RV
and thisphysiology is leading to venous congestion as shown here: a plethoric non-collapsing IVC,
an altered flow pattern on the hepatic vein here shown as a reverse d wave and this
pressure is able to be transmitted all the way to the portal vein causing greater than 50% volatility and to the
intra-renal veins causing a monophasic uh pattern now of course the treatment
of this patient was not lasik the the treatment given this was a malignant pericardium this was a
surgical pericardial window and after the surgical treatment you can see congestion completely
31:49resolved so now we have a normal hepatic vein with [a normal] S and Dvwave and then normal a wave and normal continuous non-pulsatile
portal vein and you know it might leave slightly positive intra-renal window doctor which is completely normal because now it’s not interrupted.
