Modified VExUS

Modified VExUS + RAP

1

Inferior Vena Cava

1A. Select maximal end-expiratory IVC diameter.

1B. Select inspiratory collapse / respirophasic variation.

Can RAP 20 mmHg be considered?

ASE states that RAP 20 mmHg can be considered in a markedly congested venous pattern. Look for the following together:

  • IVC >2.5 cm for the ASE 20 mmHg pattern
  • Minimal or absent respirophasic variation, not simply borderline reduction in collapse
  • Dilated hepatic veins
  • Direct venous stasis: spontaneous echo contrast and/or color-flow reflux within the IVC/hepatic venous system

Spontaneous echo contrast is visible swirling echogenic blood from very slow venous flow. Color-flow reflux is retrograde venous flow seen on color Doppler. These are stronger corroborators of markedly elevated RAP than IVC size alone.

2

Hepatic Vein Doppler

Select the dominant waveform pattern.

A = atrial reversal, S = systolic forward flow, D = diastolic forward flow. ASE considers hepatic venous diastolic predominance a secondary sign of elevated RAP in indeterminate IVC patterns.

3

Portal Vein Doppler

Enter Vmax and Vmin to calculate portal vein pulsatility fraction, or select the visual pattern.

Portal Pulsatility Fraction Calculator
PF = (Vmax − Vmin) / Vmax × 100
References
1
Mukherjee M, Rudski LG, Addetia K, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults and Special Considerations in Pulmonary Hypertension: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38(3):141-186. doi:10.1016/j.echo.2025.01.006.
View guideline
ASE RAP Guideline
2
Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12:16. doi:10.1186/s13089-020-00163-w.
View study
Original VExUS
3
Longino A, Martin K, Leyba K, et al. Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion. Chest. 2024;165(3):590-600. doi:10.1016/j.chest.2023.09.029.
View study
Prospective RHC Validation
4
Martin KC, Gill EA, Douglas IJ, Longino AA. Evaluation of a modified venous excess ultrasound (VExUS) protocol for estimation of venous congestion: a cohort study. Ultrasound J. 2025;17:7. doi:10.1186/s13089-025-00411-x.
View study
Modified VExUS Validation
5
D'Alto M, Cangiano N, Orlando A, et al. Multicenter invasive validation of the Venous Excess Ultrasound Score (VExUS) in patients referred for pulmonary hypertension. Chest. Published online August 29, 2026. doi:10.1016/j.chest.2026.08.031.
View study
Multicenter Invasive Validation
6
Bhardwaj V, Vikneswaran G, Rola P, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med. 2020;24(9):783-789. doi:10.5005/jp-journals-10071-23570.
View study
3-Site Venous Doppler
7
Andrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care. 2023;27:224. doi:10.1186/s13054-023-04524-4.
View study
Multicenter ICU Validation
8
Islas-Rodríguez JP, Miranda-Aquino T, Romero-González G, et al. Effect on Kidney Function Recovery Guiding Decongestion with VExUS in Patients with Cardiorenal Syndrome 1: A Randomized Control Trial. Cardiorenal Med. 2024;14(1):1-11. doi:10.1159/000535641.
View study
VExUS-Guided Decongestion
9
Assavapokee T, Rola P, Assavapokee N, Koratala A. Decoding VExUS: a practical guide for excelling in point-of-care ultrasound assessment of venous congestion. Ultrasound J. 2024;16:48. doi:10.1186/s13089-024-00396-z.
View practical guide
Acquisition & Interpretation