Vascular Examination

Question 1

Clinical Signs

Answer 1

• Missing limbs or digits - may be due to amputation due to ischaemia
• Scars - previous surgical procedure
• Medical equipment - mobility aids, vital signs and prescriptions

Question 2

Upper limb inspection

Answer 2

• Peripheral cyanosis
• Peripheral pallor
• Tar staining
• Xanthomata - hyperlipidaemia
• Gangrene - tissue necrosis secondary to inadequate perfusion

Question 3

Palpation

Answer 3

• Symmetrically warm
• Capillary refil <2 seconds
• > 2 secs = poor peripheral perfusion

Question 4

Pulses

Answer 4

• Radial - rate and rhythm
• Radio-radial delay - loss of synchronicity - subclavian artery stenosis, aortic dissection
• Brachial pulse - Volume and character
• BP - Wide pulse pressure >100mmHg between systolic and diastolic = aortic regurgitation and aortic dissection
• > 20mmHg between arms is abnormal and is associated with aortic dissection

Question 5

Carotid artery

Answer 5

• Carotid artery for a bruit
• Place the diaphragm of your stethoscope between thelarynxand theanterior border of the sternocleidomastoidmuscleover the carotid pulse and ask the patient totake a deep breathand thenhold itwhilst you listen.
• May be a radiating cardiac murmur.

If no bruits were identified, proceed tocarotid pulse palpation:

1.Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).

2.Gently place your fingers between thelarynxand theanterior border of the sternocleidomastoidmuscleto locate the carotid pulse.

3.Assess thecharacter(e.g. slow-rising, thready) andvolumeof the pulse.

Question 6

Abdomen

Answer 6

• Pulsation
• Deep palpation just superior to the umbilicus for AA
• In healthy individual your hands should begin to move superiorly with each pulsation
• If move outwards = AAA
• Auscultate for aortic bruits - 1-2cm above umbilicus for AAA
• Renal bruit - 1-2cm superior to the umbilicus and slightly lateral on both sides for renal artery stenosis

Question 7

Lower limb

Answer 7

• Peripheral cyanosis or pallor
• Ischaemic rubor
• Venous ulcers - typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.
• Arterial ulcers - typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).
• Gangrene
• Missing limbs, toes and fingers
• Scars
• Hair loss
• Muscle wasting
• Xanthomata

Question 8

Pulses

Answer 8

• Temp and CRT
• Femoral pulse and check for radio-femoral delay
• Auscultate over femoral pulse for bruits suggesting iliac or femoral stenosis
• Popliteal pulse
• Posterior tibial pulse
• Dorsalis pedis pulse

Question 9

Peripheral sensation

Answer 9

Ask the patient to close their eyes whilst you touch their sternum with a wisp of cotton wool to provide an example of light touch sensation.

2.Ask the patient to say “yes” when they feel the sensation.

3.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.

Question 10

Buergers test

Answer 10

Buerger’s testis used to assess theadequacyof thearterial supplyto theleg.

ToperformBuerger’stest:

1.With the patient positionedsupine, stand at the bottom of the bed andraise both of the patient’s feet to 45ºfor1-2 minutes.

2.Observethecolourof thelimbs:

• The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle.
• In a healthy individual, the entire leg should remain pink, even at an angle of 90º.
• A Buerger’s angle of less than 20º indicates severe limb ischaemia.

3.Sit the patient upand ask them tohang their legs down over the side of the bed:

• Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
• The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).

Question 11

Further assessments

Answer 11

BP
Cardio
ABPI
Upper and lower limb