TEE Fan

#POCUS #Nephpearls Great discussion overall! The answer is femoral vein. The main point of the question was that a pulsatile vessel ≠ an artery. Whether you’re placing an arterial line, a central venous line, or doing #VExUS, don’t reflexively identify a vessel based on pulsatility alone. A lot of people say, “Just use PW Doppler.” That certainly helps, but even that can fool you in cases like this. This vein had a very spiky waveform that looked arterial. The clue becomes obvious when you add the ECG: the venous spike occurs in diastole, whereas the true arterial systolic spike lines up with the QRS. I intentionally left the ECG out of the original image :) Normally, venous flow has systolic and diastolic components. With significant venous congestion, however, the systolic wave can become markedly blunted, disappear, or even reverse. In this case, the CVP was ~24 mmHg, the systolic wave essentially disappeared, and the patient had only mild TR. Also, pulsatile veins are not exclusive to severe TR, nor are they necessarily pulsations transmitted from a nearby artery. They can be quite pulsatile in congested and hyperdynamic states. Of course, anatomy comes first. Know where your probe is and what vessel should be on which side. PW Doppler adds information, and when the clinical situation allows, having an ECG trace can make the distinction much clearer.