Arterial Vascular Examination


TO START

W2I2P4E2

  • Wash your hands

  • Wear appropriate PPE

  • Introduce yourself and check patient’s Identity

  • Permission: ‘Would it be alright if I examined your legs and stomach?’

  • Privacy: Ensure curtains to the bay are closed

  • Pain: “Are you in any pain at all?” 

  • Position: Patient lying flat in bed

  • Exposure: Trouser and socks off with a sheet across hips

INSPECTION

Surroundings




Patient


Legs

  • Monitoring - ECG, pulse oximetry

  • Treatments - O2, IV access, insulin pen, GTN spray, NBM sign

  • Paraphernalia - walking aids, wheelchair, cigarettes


  • Cachectic, xanthelasma, smoker’s gaunt facies


  • Colour: pallour, mottled, cyanosis, gangrene of limbs

  • Ulcers: look at pressure points (beneath the heel, ball of the foot, malleoli, 5th metatarsal head, 1st metatarsal head, tips of toes) and between the toes. Arterial ulcers look ‘punched out’ with sharply demarcated edges.

  • Scars: from previous vascular surgery, healed ulcers or amputations. The most common scar is on the medial aspect of the lower leg (long saphenous vein harvest for coronary artery bypass graft, CABG)

  • Hair loss and shiny skin indicates peripheral arterial disease.

PALPATION

General







Pulses

  • Temperature: use the backs of your hands to compare both legs, feeling up the length of the legs to detect any change in temperature

  • Cap refill time: use the big toe (normal <2 seconds)

  • Sensation: grossly test by running you fingers up the legs and asking the patient if it feels different between legs, and along the length of each leg (diabetic neuropathy has a ‘stocking’ distribution of loss.


  • Upper limb: radial and brachial (feel at the elbow, medial to the biceps tendon)

  • Abdominal aorta: feel for a pulsatile mass in the epigastric region (>5.5cm in diameter is indication for elective repair) NB expansile mass indicates an AAA

  • Femoral pulses: feel at the mid-inguinal point (halfway between pubic symphysis and anterior superior iliac spine). DO NOT confuse with the mid-point of the inguinal ligament, halfway between the pubic tubercle and the ASIS. Offer to check for radio-femoral delay (coarctation of the aorta).

  • Popliteal pulse: bend the patients knee to between 45° and 90°. With your thumbs on the tibial tuberosity and your fingers wrapped posteriorly, press your fingers firmly in the midline to feel the pulse against the tibial plateau - expansile aneurysms here increase likelihood of AAA.

  • Dorsalis pedis: a continuation of the anterior tibial artery, felt just lateral to the extensor hallucis longus tendon, between the 1st and 2nd metatarsals (ask patient to raise their big toe to highlight the extensor hallucis longus tendon)

  • Posterior tibial: 2cm inferior  and 2cm posterior to the medial malleolus NB pressing too hard can occlude the pulses in the foot

AUSCULTATION

Aortic bruit

  • Listen at midline epigastrium, use diaphragm of stethoscope

Renal bruit



Femoral bruit

  • Listen 2cm to the left and right of the aorta. May indicate renal artery stenosis


  • Listen at the mid-inguinal point

SPECIAL TESTS

Buerger’s angle

  • With patient lying supine, raise their straight leg and note the angle at which it becomes white. The smaller the angle, the greater the arterial disease. Angle <20° indicates severe ischaemia

Buerger’s test

  • Immediately after finding Buerger’s angle, ask the patient to swing their leg off the bed and hang it down. The test is positive if the lef becomes purple/red and painful (reactive hyperaemia)


NB these tests are rarely done in practice and unpleasant for patients. ABPI is a better bedside tool for assessing disease severity

TO COMPLETE

Closure 

  • Thank the patient, ensure they are comfortable and dressed

  • Remove PPE

  • Wash hands and equipment

Examinations



Bedside tests














Investigations

(if indicated)

  • Full cardiovascular examination

  • Full lower limb neurological examination


  • Claudication distance (maximum walking distance before pain)

  • ABPI: ankle brachial pressure index

    • Take three blood pressures: brachial artery, posterior tibial and dorsalis pedis

    • Use a doppler probe instead of a stethoscope

    • Divide the highest ankle systolic pressure by the brachial systolic pressure

    • 0.5-0.9 = peripheral arterial disease

    • <0.5 = acute limb ischaemia (look for 6Ps: pain, pallour, ‘perishingly’ cold, pulseless, paraesthesia (burning/tingling) and paralysis)

    • If >1m lower limb arteries are likely calcified and inelastic from diabetes


  • Arterial duplex

  • Angiography