Peripheral Vascular Examination

 

Inspect

• Patient stands, to bring out any varicosities: long saphenous on medial leg, or short saphenous on posterior lower leg.
• Then patient lies on bed, with upper body at 45°.
• Ulcers on pressures points: between toes, on heel. Arterial ulcers look 'punched out', and are painful (exacerbated by elevation). Venous ulcers have a rough edge, and may be warm and swollen.
• Signs of PVD: hair loss, pallor, coolness, cyanosis, shiny skin, dry skin, deformed toe nails, gangrene. Check the face for signs of high cholesterol.
• Signs of venous disease: varicosities, brown haemosiderin deposits, lipodermatosclerosis (atrophy and ↓elasticity).

Palpate

Arterial:

• Note temperature.
• Cap refill on hand and big toe nail (≤3 seconds is normal).
• Check pulses: radial, brachial, carotid, abdominal aortic aneurysm, femoral, popliteal, posterior tibial, and dorsalis pedis. Note the rate, rhythm, volume, and character. Popliteal often hard to feel, especially if obese, so don't worry if can't be felt.
• Check radio-radial and radio-femoral delay.
• Brief sensory exam of lower limb, which may be impaired in acute limb ischaemia.

Venous:

• Varicose veins may feel warm and tender if inflamed (thrombophlebitis).

Auscultate

• Arterial: carotid, aortic, or femoral bruits. Have them breath in while listening for carotid.
• Bruit on varicosities suggests an AV malformation.

Special tests

Arterial

Buerger's test:

• Buerger's angle: lift both legs to 45°, wait 1 minute, and the feet (including soles) should turn from pink to pale. If this occurs below 20°, it is pathological, but even extreme pallor at 45° is abnormal.
• Buerger's sign: bring legs down from elevation, patient sits up, and hangs legs over the side of the bed. Note if they go from pale to flushed red due to reactive hyperaemia, a sign of ischaemia. Ideally wait for 2-3 minutes.

Venous

Cough impulse test:

• Palpate SFJ while patient coughs.
• A cough impulse suggests saphena varix (dilated vein at SFJ).

Tap test:

• Palpate SFJ while tapping varicose veins.
• If impulse is felt, it suggests valvular incompetence.

Trendelenburg test:

• Elevate the patient's leg as far as possible and massage the leg to empty varicosities.
• Place a tourniquet (or 2 fingers) on the saphenofemoral junction (SFJ, 4 cm inferio-lateral to pubic tubercle), then have the patient stand, with the tourniquet/fingers still in place.
• If tourniquet prevents rapid re-filling – noting that re-filling will happen from below anyway in about 5 seconds – it suggests SFJ incompetence. The tourniquet is then removed, and rapid filling confirms that as the site of incompetence.
• If there is rapid filling, it suggests the problem is lower down, so redo the test with the tourniquet just above the knee (mid-thigh perforator), then below the knee (short sapheno-popliteal).
• Rarely done in practice, as doppler US is more reliable.

Closing

Doppler US:

• Ankle-brachial pressure index (ABPI): doppler to detect ratio of systolic pressure at the ankle (the highest of the PT or DP) to the brachial pulse. <0.9 suggests PVD, <0.6 causes rest pain, and <0.3 suggests impending gangrene.
• Venous valvular incompetence: squeezing the lower leg distal to the probe (at the SFJ or SPJ) should cause a whoosh, then no whoosh on release; a 2nd whoosh suggests incompetence (regurgitation).

Also:

• Full neuro exam of the lower limb.
• Capillary glucose.
• Swab any ulcers that may be infected.
• An abdo exam, as increased abdominal pressure can cause varicose veins.