5. VExUS Score Step 2: HEPATIC Vein Doppler Assessment

VExUS Score Step 2: HEPATIC Vein Doppler Assessment

Acquiring the Hepatic Vein View with Ultrasound:

There are three hepatic veins: the right, middle, and left hepatic veins. You can use any of these veins to evaluate for hepatic vein Doppler patterns but the middle and right hepatic are usually the most accessible since the L hepatic vein view can be obscured by bowel/stomach gas. Below is a CT figure showing approximately where you should place your probe to target specific hepatic veins. Notice that it is NOT directly midline of the patient (I made this mistake when first trying to see the hepatic veins).

So here are the step to get the Hepatic Vein Doppler Tracings:

  1. Get a 2-D image of the IVC and hepatic veins.
  2. Place color flow Doppler over the hepatic veins as they enter the IVC. You should see BLUE flow (away from probe)
  3. Place your pulse wave Doppler gate on a hepatic vein prior to it entering the IVC
  4. Initiate Pulse wave Doppler
Hepatic Veins
Hepatic Veins Entering IVC

Interpretation of Hepatic Vein Doppler findings:

The hepatic vein Doppler is composed of a systolic (S wave) and diastolic (D wave). As venous congestion increases, there will be alterations of these waves with these typical patterns:

Normal Hepatic Vein Doppler: S>D

Normal Hepatic Vein Doppler
Hepatic Vein Doppler Grade 0

Mild Hepatic Vein Abnormality: S<D

Mild Hepatic Vein Abnl
Hepatic Vein Doppler Grade 1

Severe Hepatic Vein Abnormality: S Reversal

Severe Hepatic Vein Abnl
Hepatic Vein Doppler Grade 2