Hepatic vein, portal vein and intrarenal venous Doppler side by side, with the IVC, so you can grade venous congestion the way you would at the bedside.
IVC . Read the three waveforms, then pick the grade.
Freeze the screen to measure.
| Grade | IVC | Doppler patterns |
|---|---|---|
| 0 | < 2 cm | Not graded further. No congestion. |
| 1 | ≥ 2 cm | Any mix of normal and mildly abnormal |
| 2 | ≥ 2 cm | One severely abnormal pattern |
| 3 | ≥ 2 cm | Two or three severely abnormal patterns |
| Normal | Mild | Severe | |
|---|---|---|---|
| Hepatic vein | S > D | S < D | S reversal |
| Portal vein | PI < 30% | PI 30 to 49% | PI ≥ 50% |
| Intrarenal vein | Continuous | Biphasic, S and D | Monophasic, D only |
Subcostal or right lateral intercostal window. PW sample volume in the middle or right hepatic vein 1 to 2 cm from the IVC junction, with ECG on. Flow toward the heart sits below the baseline. The S wave falls after the QRS, the D wave after the T wave, and the small retrograde a wave sits above the baseline just before the next QRS. Severe tricuspid regurgitation also reverses S, independent of volume status.
Right intercostal window, main or right portal vein. Normal flow is continuous and hepatopetal, above the baseline. PI = (Vmax − Vmin) / Vmax. A value at or above 50%, including to-and-fro flow, is severe. Thin, healthy patients can show mild portal pulsatility without congestion, and cirrhosis can mask it.
Posterior or lateral flank approach. Use color to find an interlobar vessel pair, then PW with a low scale so the artery shows above the baseline and the vein below. Normal venous flow is continuous. Congestion breaks it into separate S and D phases, then leaves only a diastolic D phase. Chronic kidney disease can alter these patterns.
Atrial fibrillation removes the a wave and often blunts the S wave, so the hepatic vein can look abnormal without congestion. Read the portal and renal patterns with that in mind.