Objective: Venous pulsatility on Doppler tracings is characterized by retrograde flow during the atrial systole of the cardiac cycle. A correlation between increased right atrial pressure (RAP) and pulsatile venous flow in the lower limbs has been documented, as well as in the hepatic and splenic veins in the settings of increased RAP and tricuspid regurgitation (TR). However, there is a general lack of consensus amongst readers about the inference of pulsatile wave form, ranging from being normal physiology to being possible elevated RAP or TR. Our study attempts to resolve the disagreement by demonstrating the relationship between lower extremity pulsatile flow and cardiopulmonary pathophysiology.
Methods: A single-center, retrospective chart review of patients with bilateral pulsatile venous flow of the common femoral veins (CFV) and concurrent echocardiogram within 36 hours of the resulted venous ultrasound was conducted between 1/1/2015 to 8/31/2021. The selected patients had the following data points collected: age, gender, presence of true pulsatile and pseudo-pulsatile flow, RAP, degree of TR, and pulmonary artery pressure (PAP). RAP was considered elevated when measurements ≥ 8 mmHg. PAP was considered elevated when measurements ≥ 25 mmHg. TR levels will be classified as 0-3: 0 = normal, 1 = mild, 2 = moderate, and 3 = severe. True pulsatile flow was identified when the waveform had an antegrade and a retrograde component, whereas a pseudo-pulsatile was defined as pulsatile flow without any retrograde component. The primary outcome was presence of increased RAP in patients with pulsatile flow in CFV. Secondary outcomes were presence of elevated PAP and moderate to severe TR in patients with pulsatile flow in CFV.
Results: A total of 422 patients were identified and included in the study. On venous ultrasound, 409 of the 422 patients were found to have a true pulsatile waveform in their bilateral CFV. Out of the 409, 403 patients had data regarding TR on echocardiogram. Of those who had true pulsatile waveform, 19.6% had severe (79/403), 33.5% moderate (135/403), 28.3% mild (114/403), and 18.6% no TR (75/403). Of 370 patients with measured PAP, 93.5% with true pulsatile waveform had an elevated PAP (346/370) and only 6.5% had a normal PAP (24/370). Of 405 patients with a measured RAP, 41.2% who had true pulsatile waveform had an elevated RAP (167/405), while 58.8% had a normal RAP (238/405) (Table 1).
Conclusions: Patients with venous pulsatility on duplex are likely to have elevated pulmonary artery pressures. Overall, 81.4% of patients with venous pulsatility had some degree of TR (328/403). Patients with venouspulsatility on lower extremity duplex should be offered a cardiac echocardiogram.