We read with great interest the article entitled “Venous Excess Ultrasound Score (VExUS) Association with Disease Severity in Acute Pulmonary Embolism” [1], which, to our knowledge, is the first observational study evaluating the VExUS protocol in patients with acute pulmonary embolism (PE). In this cohort of 80 patients, the authors report an association between venous congestion assessed by VExUS and PE severity, suggesting that retrograde venous congestion may reflect right-sided hemodynamic impairment and serve as a dynamic biomarker of disease severity. Patients classified as low risk had a VExUS score of 0; the portal vein pulsatility index showed the strongest association with PE severity, followed by hepatic vein Doppler patterns, whereas inferior vena cava diameter alone did not adequately reflect disease severity.

Nevertheless, several aspects deserve further consideration. First, the relatively small sample size—particularly in the high-risk group (only six patients)—limits the robustness of the statistical estimates. In addition, the study was conducted in a single center and excluded patients with pulmonary hypertension, heart failure, or pregnancy, which may restrict generalizability to real-world clinical practice where such comorbidities are common [2].

Second, the evaluation was performed at a single time point. Serial VExUS measurements and their association with clinically relevant outcomes such as mortality, shock, intensive care admission, or post-pulmonary embolism syndrome were not assessed. Longitudinal evaluation of venous congestion could provide insight into the dynamic evolution of the disease [3].

Third, variability in the timing of anticoagulation initiation may influence the interpretation of findings. The study does not report the interval between hospital admission, treatment initiation, and ultrasound evaluation. If VExUS assessment occurs after anticoagulation or reperfusion therapy has started, venous congestion may already be partially improved, potentially affecting results [4]. Moreover, it is unclear whether VExUS findings influenced therapeutic decision-making.

Fourth, the patient flow raises some questions. Although 90 patients were screened and six excluded—suggesting 84 eligible patients—the final analysis included 80. This discrepancy warrants clarification. Additionally, only one patient was excluded due to ultrasound timing outside the predefined window, which may imply continuous screening, though this is not specified.

Another important point is the comparison with established risk stratification in acute PE. Current guidelines classify patients based on comorbidities (often incorporated into the simplified Pulmonary Embolism Severity Index [sPESI]), hemodynamic status, biomarkers, and imaging findings, a validated and widely used framework guiding therapeutic decisions [5]. It therefore remains unclear what additional value VExUS provides beyond this system.

Finally, the study does not compare VExUS findings with conventional transthoracic echocardiography, the cornerstone for detecting right ventricular dysfunction in acute PE [4]. The authors do not report how many patients underwent echocardiography or provide details on sPESI scores, cardiac biomarkers, or echocardiographic evidence of right ventricular dysfunction. These data would clarify patient stratification according to ESC criteria and allow a more meaningful comparison with VExUS findings. In addition, Doppler abnormalities in portal or renal veins may reflect pre-existing conditions unrelated to the acute event, potentially reducing the specificity of VExUS.