Peripheral arterial examination

Question 1

What do you look out for in peripheral arterial examination? (environment and patient)?

Answer 1

Environment:

• pulse oximeter/ECG
• GTN spray/O2 and other medications
• insulin pen
• mobility aids

Patient:

• alert
• comfortable at rest/pain
• body habitus-obese/cachectic
• smoker’s facies
• cyanosed

Question 2

What do you look for in the hands?

What do you look for in the arms?

Answer 2

• peripheral cyanosis/mottling of the skin
• tendon xanthomata-hypercholesterolaemia is a risk factor
• tar staining
• capillary blood glucose
• check for any scarring-radial artery scarring for CABG
• check for temperature-distal to proximal
• check for sensation-distal to proximal
• capillary refill <2s
• radial pulse-rate, rhythm, volume and character
• radio-radial delay; radio-femoral delay: aortic coarctation

Arms:

• check for brachial pulse (medial to biceps tendon)
• check for BP on both sides

Question 3

What is unequal BP suggestive of?

Answer 3

• aortic coarctation
• aortic dissection
• subclavian artery occlusion (less on side of occlusion)

Question 4

What do you want to look for in the neck/abdomen?

What do you want to check in groin area?

Answer 4

Neck:

• carotid pulse

abdomen:

• check for any scars-midline laparotomy/T shaped scar may suggest emergency AAA repair
• palpate above umbilicus to check for triple AAA. Should be pulsatile and not expansile
• If expansile, state the size of this
• auscultate AA and renal arteries for bruits

Groin area:

• feel femoral artery (midinguinal point-midway between ASIS and pubic symphysis)
• auscultate

Question 5

What do you want to inspect in legs? How do you check for the pulses?

Answer 5

Inspection of legs:

• peripheral cyanosis/mottled skin appearance
• skin-shiny?dry?
• hair distribution
• brittle nails
• scars-saphenous vein grafting for CABG
• arterial/venous/neuropathic ulcers
• check for temperature
• check for sensation-distal to proximal
• check for popliteal pulses
• ask patient to bend their legs; with thumb on tibial tuberosity and 2-3cm below the crease
• check for dorsalis pedis
• lateral to extensor hallucis longus
• check for posterior tibial pulse
• 2cm below and 2cm behind the medial malleolus

Question 6

What other investigations would you recommend?

Answer 6

Bedside investigations:

• cardiovascular and peripheral venous examination
• peripheral neurological examination
• capillary blood glucose
• ECG
• buerger’s test if indicated
• ABPI
• check claudication distance; walking distance

Invasive:

Bloods (FBC, U&Es, lipids, ESR/CRP, glucose and HbA1c, thrombophilia screen if indicated)

Imaging:

• duplex ultrasound
• CT angiogram