The aim of this case is to visually showcase severe right-sided congestion. As mentioned earlier, eVExUS, or ‘extended VExUS‘, involves examining more veins than the traditional trio of hepatic, portal, and intrarenal (in cases where they are inaccessible or unreliable). Although in this instance the severity of congestion is obvious and eVExUS is not necessary for management, the objective is to depict various waveforms for educational purposes.

Apical 4-chamber view reveals leftward bulging of the interventricular septum throughout the cardiac cycle, indicating elevated right atrial pressure. Also note significantly impaired left ventricular function. This patient had known ischemic cardiomyopathy, obstructive sleep apnea and pulmonary hypertension. Right ventricular outflow tract (RVOT) Doppler shows systolic notching (the ‘Flying W’ sign) suggestive of pre-capillary pulmonary hypertension.

RV inflow view exhibits qualitatively moderate to severe tricuspid regurgitation, which has worsened compared to prior formal echocardiogram, likely due to superimposed fluid overload. Pacemaker wire is seen.

Plethoric inferior vena cava indicative of elevated right atrial pressure.

Hepatic vein Doppler demonstrates systolic flow reversal.

Portal vein Doppler displays a 100% pulsatile waveform.

Intrarenal venous Doppler exhibits a monophasic pattern (D-only below the baseline) with an elevated stasis index, meaning more flow interruption in a given cardiac cycle. Above-the-baseline spikes represent arterial waveform (systole). Absent diastolic flow indicates very high resistive index (1) possibly contributed by intrinsic renal factors (such as uric acid induced vasoconstriction, ATN, hepatorenal pathophysiology) in addition to venous congestion.

Splenic vein Doppler shows a 100% pulsatile waveform, with the above-the-baseline waveform representing the splenic artery waveform.

Femoral vein waveform reveals an elevated stasis index and diastolic-predominant flow.

Popliteal vein waveform is similar to the femoral vein waveform. This component may be particularly helpful in prone patients where it is difficult to access other veins.

Superior vena cava waveform displays systolic reversal similar to that of the hepatic vein. The velocities are lower due to the suboptimal Doppler angle; this is observed in a modified RV inflow view (parasternal window).

Internal jugular vein ultrasound is akin to that of the femoral vein, with less prominent flow reversal compared to SVC possibly due to valve mitigation.