Venous excess doppler ultrasound: What radiologists should know in 2026.

Systemic venous congestion is increasingly recognized as a key contributor to organ dysfunction and adverse outcomes, particularly in the cardiorenal and critical care settings. Elevated right-sided cardiac pressures are transmitted retrogradely to the hepatic, splanchnic, and renal venous systems, leading to impaired organ perfusion, increased interstitial pressure, and complications such as acute kidney injury. Conventional clinical markers and biomarkers of congestion lack sensitivity for detecting early or subclinical venous hypertension. In contrast, ultrasound, particularly when incorporating abdominal venous Doppler assessment, enables a more granular, physiologically grounded evaluation of congestion. The venous excess ultrasound (VExUS) score integrates inferior vena cava assessment with hepatic, portal, and intrarenal venous Doppler waveforms to provide a structured framework for grading venous congestion. VExUS has been associated with renal outcomes, and morbidity and mortality in heart failure, and dynamic changes in venous Doppler patterns appear to carry prognostic significance. This review describes the physiologic basis of venous Doppler abnormalities, outlines the components and grading of the VExUS system, and highlights common technical and interpretive pitfalls that affect reliable assessment. Particular emphasis is placed on waveform morphology, electrocardiographic correlation, and optimization of Doppler acquisition. Given that abdominal Doppler studies are frequently performed for indications unrelated to heart failure, radiologists are uniquely positioned to recognize venous congestion on routine imaging. Incorporation of VExUS principles into radiologic reporting, along with standardized acquisition and multidisciplinary education, may enhance the clinical relevance of abdominal and renal vascular examinations and support earlier, physiologically informed hemodynamic intervention. This narrative review synthesizes current evidence, discusses technical and interpretive considerations, and provides practical guidance for radiologists incorporating VExUS into practice.