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

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.