Peripheral vascular exam

• General inspection clinical signs:

  • Inspect patient from end of the bed
  • Missing limbs/digits: may be due to amputation secondary to critical ischaemia
  • Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers
  • Limb pallor
• General inspection objects and equipment:

  • Medical equipment - dressings and limb prosthesis
  • Mobility aids
  • Vital signs
  • Prescriptions
• Upper limb inspection:

  • Peripheral cyanosis: bluish discolouration of the skin associated with low SpO2 (e.g. may be present in the peripheries in PVD due to poor perfusion).
  • Peripheral pallor: a pale colour of the skin that can suggest poor perfusion (e.g. PVD).
  • Tar staining: caused by smoking, a significant risk factor for cardiovascular disease
  • Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow.
  • Gangrene: tissue necrosis secondary to inadequate perfusion.
• Upper limb temperature

  • In healthy individuals, the upper limbs should be symmetrically warm, suggesting adequate perfusion.
  • A cool and pale limb is indicative of poor arterial perfusion.
• Upper limb capillary refill time:

  • In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
  • A CRT that is greater than two seconds suggests poor peripheral perfusion.
• Upper limb pulses:

  • Radial pulse + radio-radial delay (assess rate and rhythm)
  • Brachial pulse (assess volume and character)
  • Blood pressure
• Radial pulse:

  • Assess rate and rhythm
  • Causes of radio-radial delay:
  • Subclavian artery stenosis
  • Aortic dissection
• Blood pressure:

  • Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection.
  • A more than 20 mmHg difference in BP between arms is abnormal and is associated with aortic dissection.
• Carotid pulse:

  • Auscultate - bruit - suggests underlying carotid stenosis
  • Palpate - character and volume
• Abdomen inspection:

  Inspect the abdomen looking for any obvious pulsation. The abdominal aorta can be located in the midline of the epigastrium.
• Abdomen palpation:

  • In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
  • If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).
• Abdomen auscultation:

  • Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.
  • Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.
• Lower limb inspection:

  • Peripheral cyanosis - poor perfusion
  • Peripheral pallor - poor perfusion
  • Ischaemic rubour
  • Venous ulcers - typically medial aspect of the ankle
  • Arterial ulcers
  • Gangrene
  • Missing limbs/digits
  • Scars e.g. bypass surgery
  • Hair loss
  • Muscle wasting
  • Xanthomata
  • Paralysis - ask patients to wiggle toes
• Lower limbs temperature:

  • In healthy individuals, the lower limbs should be symmetrically warm, suggesting adequate perfusion.
  • A cool and pale limb is indicative of poor arterial perfusion.
• Lower limb capillary refill time:

  • In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
  • A CRT that is greater than two seconds suggests poor peripheral perfusion.
• Lower limb pulses:

  • Femoral
  • Popliteal
  • Posterior tibial
  • Dorsalis pedis
• Lower limbs femoral pulse:

  • Palpate - mid inguinal point - check is present and assess volume
  • Assess for radio-femoral delay - coarctation of the aorta
  • Auscultate for bruits - femoral or iliac stenosis
• Gross peripheral sensation:

  Using the wisp of cotton wool, begin to assess light touch sensation moving distal to proximal, comparing each side as you go by asking the patient if it feels the same:

  • If sensation is intact distally, no further assessment is required.
  • If there is a sensory deficit, continue to move proximally until the patient is able to feel the cotton wool and note the level at which this occurs.
• Buerger's test:

  • Assesses adequacy of the arterial supply to the leg
  • With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
  • Observe the colour of the limbs - development of pallor indicated that peripheral arterial pressure is unable to overcome the effects of gravity
  • Sit the patient up and hang legs over side of bed
  • Leg will initially turn blue due to passage of deoxygenated blood through ischaemic tissue
  • The leg will then become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation
• Further assessments and investigations to consider:

  • Doppler to confirm absence of any pulses unable to palpate
  • Cardiovascular examination
  • ABPI
  • Upper and lower limb neurological examination