Femoral vein pulsatility: a simple tool for venous congestion assessment

Figures

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  Fig. 1. Normal FVD waveform antegrade flow more than retrograde flow with respiratory variation and the flow can be described as antegrade mildly pulsatile uninterrupted pattern

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  Fig. 2. FVD suggestive of venous congestion. Retrograde velocity of more than 10 cm/s (pulsatile with flow reversal)

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  Fig. 3. FVD suggestive of venous congestion. Retrograde flow 1/3rd more than antegrade flow (pulsatile with flow reversal)

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  Fig. 4. Proposed Guytonian curve on correlation of VExUS with FVD. This is a modified Guytonian curve as a hypothesis to our findings. The normal Frank starling curve with venous return curve intersecting at ascending portion shows a collapsing IVC (vexus grade 1) correlating with antegrade predominantly monophasic Femoral venous Doppler flow and the lower Frank Starling curve with venous return intersection at flat portion shows pulsatile portal vein correlating with VExUS grade 3 and corresponding pulsatile femoral venous Doppler without respiratory variation.

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  Fig. 5. Correlation between right atrial pressure waveform (RAP), right ventricular pressure waveform (RVP), hepatic venous flow (HVF), interlobar renal venous flow (IRVF), portal venous flow (PVF) and femoral venous flow (FVF) with progressive right ventricular (RV) dysfunction and venous congestion in normal patients (A, D, G, J, M, P). Typical patterns are commonly observed in patients with mild (B, E, H, K, N, Q) and severe (C, F, I, L, O, R) RV dysfunction. AR atrial reversal Doppler flow velocity; D diastolic Doppler flow velocity; Ppa pulmonary artery pressure, Prv right ventricular pressure, S systolic Doppler flow velocity. (Adapted with permission of Couture et al. [9])

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  Fig. 6. FVD and CVP waveform in same patient for comparison. A High CVP (mean = 24.4 cmH2O) with ECG correlation. B Corresponding femoral venous Doppler with ECG correlation. As the central pressure rises, the vein rounds out; giving femoral venous Doppler a pulsatile pattern. FVD is an inverse representation of CVP waveform. As the CVP rises and stretches the atrium, the pattern of CVP changes and FVD reflects the same. When CVP rises, Y descent exceeds X descent; accordingly, the FVD ‘d Wave’ being more prominent than the ‘s Wave’. FVD shows a prominent retrograde ‘a Wave’ with velocity of 20 cm/s indicating venous congestion

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  Fig. 7. Measure of agreement between VExUS, FVD and CVP