Diagnostic and Prognostic Value of the Venous Excess Ultrasound Grading System: A Systematic Review and Meta-Analysis

OBJECTIVES: The venous excess ultrasound (VExUS) grading system has gained recognition in acute and critical care medicine as a promising approach to evaluate venous congestion and optimize fluid management. However, the diagnostic accuracy and prognostic value of VExUS remain unclear. DATA SOURCES: PubMed, Embase.com, Web of Science (Core Collection), and Wiley/Cochrane Library from inception to May 19, 2025, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and in collaboration with a medical information specialist. STUDY SELECTION: Study selection was systematically performed by a panel of authors. A total of 32 studies were included, consisting of 3142 patients, with six diagnostic, 22 prognostic studies, and four studies that reported on both diagnostic and prognostic outcomes. DATA EXTRACTION: Relevant data were extracted by two authors, and the corresponding authors were contacted when necessary. DATA SYNTHESIS: For diagnostic studies, no meta-analysis could be performed. Studies suggest moderate to good diagnostic accuracy for detecting increased central venous and right atrial pressures (sensitivity 78-95%, specificity 80-90%). Prognostic studies in cardiac patients found an association between VExUS greater than or equal to 2 and acute kidney injury (AKI; odds ratio [OR], 4.44; 95% CI, 2.34-8.43; moderate certainty) and mortality (OR, 3.17; 95% CI, 1.30-7.75, low certainty). For critically ill patients, no associations between VExUS greater than or equal to 2 and AKI (OR, 1.45; 95% CI, 0.70-2.99; very low certainty) and mortality (OR, 1.25; 95% CI, 0.77-2.03; low certainty) were found. Per-patient analysis showed an association between VExUS 3 and mortality for all patients and an association with AKI for cardiac patients. CONCLUSIONS: Results from this systematic review and meta-analysis suggest that VExUS has moderate to good accuracy to diagnose increased central venous pressure and right atrial pressure. In cardiac patients, higher VExUS grades are associated with AKI and mortality, but in critically ill patients, the association between VExUS grades and outcomes is less clear.