Peripheral Vascular Examination

Question 1

What is involved in the initial inspection stage of the examiantion of the arterial system of the upper and lower limbs? (general area, appearance, hands)

Answer 1

• General inspection of the bed area for clues
• Inspection of the patient (colour, build, comfort, position etc.)
• Inspect the hands for:
o Colour (pallor of the palmar creases; peripheral cyanosis)
o Capillary refill
o Nicotine staining

Question 2

What is the involved in the initial palpation stage of the examination of the arterial system of the upper and lower limbs? (pulses)

Answer 2

• Check and compare radial pulses (rate, rhythm, volume, radio-radial delay?)
• Palpate the ulnar (volume) and brachial (volume and character) pulses
• Perform Allen’s test (Compress the ulnar and radial arteries at the wrist. Ask the patient to make a tight fist then release it. Release one of the arteries and observe blood flow back into the hand. Repeat but release the other artery. Check that both arteries perfuse the hand fully i.e. that the palmar arches are intact)
• Check the blood pressure in both arms
• Palpate the carotid pulses (one at a time). Assess character and volume.

Question 3

What is involved in the secondary inspection of the examination of the arterial system of the upper and lower limbs? eyes, mouth, abdomen, legs, feet, and toes

Answer 3

• Examine the eyes for:
o Subconjunctival pallor (anaemia)
o Corneal arcus (hyperlipidaemia

• Assess the lips and tongue for:
o Dehydration
o Central cyanosis

• Inspect the abdomen for scars, visible masses and visible pulsations 
• Inspect the legs, feet and toes for: 
o Symmetry 
o Colour 
o Scars 
o Oedema 
o Trophic changes 
▪ Loss of hair 
▪ Shiny skin 
▪ Wasting of subcutaneous tissues 
o Ulceration (describe site, depth, size, margins, ulcer bed, exudate, odour etc.)

Question 4

What is involved in the secondary palpation stage of examination of the arterial system of the upper and lower limbs? (aorta and lower limb pulses)

Answer 4

• Palpate the
o Aorta
o Femoral pulses
o Popliteal pulses
o Dorsalis pedis and posterior tibial pulses
• Check light-touch sensation and capillary refill in the toes
• Assess power in the foot/leg

Question 5

What is involved in the auscultation stage of the examination of the arterial system of the upper and lower limbs?

Answer 5

o Carotids
o Subclavian arteries
o Aorta (a bruit can be heard in thin healthy patients)
o Femoral arteries (Note that there is no bruit over an occluded vessel and severe stenosis can be present without an audible bruit.)

Question 6

What special tests are involved in the auscultation stage of the examination of the arterial system of the upper and lower limbs?

Answer 6

Perform Buerger’s test (this assesses critical ischaemia):

o With the patient supine, elevate both legs to an angle of 45° and hold for one to two minutes. Pallor of the feet indicates ischemia. The poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale (Buerger’s Angle)
o Then sit the patient up and ask them to hang their legs down over the side of the bed at an angle of 90°. Gravity aids blood flow and colour returns in the ischemic leg. The skin at first becomes blue, as blood is deoxygenated in its passage through the ischemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation. Both legs should be examined simultaneously as the changes are most obvious when one leg has a normal circulation, (the time it takes to become pink/red relates to the severity or ischemia – Buerger’s time)

• Calculate the ankle-brachial pressure index (ABPI) by dividing the highest systolic blood pressure in the arteries at the ankle by the higher of the two systolic blood pressures in the arms. Significant arterial disease is indicated by an ABPI of <0.8.

Question 7

Describe the inspection stage of the examination of the lower limbs for varicose veins and chronic venous insufficiency?

Answer 7

• Inspect the legs for:
o Varicosities, particularly in the distribution of the long saphenous vein (medial thigh and leg) and short saphenous vein (back of leg)
o Venous eczema
o Oedema due to venous stasis o Lipodermatosclerosis (scarring of the skin and fat)
o Haemosiderin deposition
o Venous ulceration (usually in the gaiter area above the medial malleolus)
o Scars (indicating previous surgery or healed ulceration)
• Identify the saphenofemoral junction (SFJ). This is located 4cm lateral and 4cm inferior to the pubic tubercle.
o Inspect for a saphenovarix (varicosities at the SFJ)

Question 8

Describe the palpation stage of the examination of the lower limbs for varicose veins and chronic venous insufficiency?

Answer 8

• Perform the Cough test by putting your finger on the SFJ and asking the patient to cough. Palpate for thrills at the SFJ.
• Perform the Tap test by putting your finger on the SFJ and putting a finger of your other hand on any varicosities in the long saphenous vein distribution. Tap on the SFJ and if it is incompetent, you will feel the transmitted percussion wave in the varicosities further down the leg.

Question 9

What are the special tests for the examination of the lower limbs for varicose veins and chronic venous insufficiency?

Answer 9

• Perform the Trendelenburg test (tourniquet test). Ask the patient to lie flat. Raise the leg and keep it raised for a few minutes to exsanguinate as much blood as possible. Apply a tourniquet high around the thigh. Ask the patient to stand up and inspect to see whether the varicose veins refill. If not, the problem originates at the SFJ. If the veins do refill, repeat the test at the mid-thigh perforators, the saphenopopliteal junction and the mid-calf perforators. (not required for OSCE).
• Perform Perthe’s test to assess the patency of the deep veins. Ask the patient to lie down. Without exsanguinating the leg, apply a tourniquet around the thigh. Ask the patient to stand and rock up and down onto his tiptoes ten times. If the superficial veins empty, the deep veins must be patent. (not required for OSCE).
• Perform auscultation using a Doppler probe on the SFJ. Squeeze the calf/ thigh. You should hear a single “whoosh” as the blood is squeezed from the long saphenous vein into the femoral vein. A second “whoosh” indicates incompetence of the SFJ as the blood falls back into the long saphenous vein past the incompetent valve.
• Repeat the Doppler probe auscultation at the saphenopopliteal junction in the popliteal fossa. To enable you to squeeze the calf, the patient will need to relax their calf muscles by transferring most of their weight onto the other limb.
• Examine the abdomen to exclude an abdominal or pelvic cause of raised venous pressure.