Subxiphoid IVC View

Subxiphoid IVC View

Technique

  • To obtain a view of the IVC, the probe is placed in the subxiphoid space similar to the subxiphoid cardiac view but with the ultrasound beam pointed deep towards the patient’s back. 
  • To obtain a longitudinal view the probe indicator should be directed towards the patient’s head. The probe should be heeled or rocked towards the patient’s head so that both the hepatic veins draining into the IVC and the IVC draining into the right atrium are visualized (Figure 27).
  • To obtain a transverse view the probe indicator is directed to the patient right in emergency convention and the patient’s left in cardiology convention. 
  • Adjust the depth to ensure the full IVC is seen on the bottom of the screen. 
  • Adjust gain to ensure that blood within the IVC appears black. 

 

Figure 26: IVC External Landmarking

 

Note: Emergency vs Cardiology convention

The subxiphoid IVC long axis view will vary in appearance on the screen whether you are using emergency or cardiology convention. With the probe marker directed to the patient’s head the images on screen will appear as mirror images of each other depending on whether your screen marker is on the left, as in emergency convention, or on the right as in cardiology convention. In the emergency convention the IVC can be seen draining into the heart on the left side of the screen, in cardiology convention this will appear on the right hand side.

The subxiphoid IVC transverse view will appear the same on the screen whether you are using emergency or cardiology convention. This is because both the probe markers and screen markers are oriented opposite, resulting in the same net image on screen 

Figure 27. IVC View Emergency Medicine Convention. 

Figure 28. IVC View Cardiology Convention. 

Tips: 

  • This window can be challenging to obtain in patients with obesity, abdominal pain or lots of bowel gas as it uses the liver as an acoustic window to view the heart.  
  • If able, having the patient bend their legs can help relax the abdominal wall. Asking the patient to take a deep breath in can also bring the diaphragm and heart towards the probe. 
  • It is common to mistake the aorta for the IVC as they are parallel and in close proximity. To avoid this, the IVC should be tracked until it is seen entering the RA. Additionally, the aorta should be pulsatile, but sometimes aortic pulsations can transmit to the IVC. If in doubt, visualize both in the transverse plane or use color doppler to determine direction of blood flow. 

 

What Am I Looking At?

For the longitudinal view of the IVC, the image will display the liver, hepatic veins (draining into IVC), and the IVC as it drains into the right atrium (Figure 29).

If starting from an A/P or cross-sectional of IVC, both the IVC and the abdominal aorta will be seen anterior to a thoracic vertebral body. The abdominal aorta will be anterior and to the (patient’s) left of the vertebral body, while the IVC will be anterior and to the (patient’s) right of the vertebral body (Figure 30)

Figure 29: IVC View in the EM Convention 

 

Figure 30: Subxiphoid IVC transverse view, emergency medicine convention

Clinical Utility

This view allows the provider to assess size, distensibility or collapsibility of the IVC as well as to make comparison of the IVC and aorta diameter.