Peripheral Vascular History and Examination

Question 1

What should be exposed and what position should the patient be in before commencing a peripheral vascular examination?

Answer 1

● Adequately expose the patient’s limbs and abdomen for the examination (offer a blanket to allow exposure only when required).
● Position the patient on the bed, with the head of the bed at 45°.

Question 2

What clinical signs may you observe when completing a general inspection during a peripheral vascular examination?

Answer 2

● Missing limbs / digits
● Scars

Question 3

What may missing limbs / digits be suggestive of when completing a general inspection of a peripheral vascular exam?

Answer 3

● May be due to amputation secondary to critical ischaemia.

Question 4

What may scars be suggestive of when completing a general inspection of a peripheral vascular exam?

Answer 4

● May indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.

Question 5

What objects or equipment may be seen during a general inspection during a peripheral vascular exam?

Answer 5

● Medical equipment - dressings or limb prosthesis
● Mobility aids
● Vital signs
● Prescriptions

Question 6

What should be assess on the upper limb during a peripheral vascular exam?

Answer 6

● Inspection
● Temperature
● Capillary refill time
● Pulses
● Blood Pressure

Question 7

What clinical signs may be observed on the upper limb during a peripheral vascular exam?

Answer 7

● Peripheral cyanosis
● Peripheral pallor
● Tar staining
● Xanthomata
● Gangrene

Question 8

What may peripheral cyanosis be suggestive of when completing a peripheral vascular exam?

Answer 8

● Bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).

Question 9

What may peripheral pallor be suggestive of when completing a peripheral vascular exam?

Answer 9

● A pale colour of the skin that can suggest poor perfusion (e.g. PVD).

Question 10

What may tar staining be suggestive of when completing a peripheral vascular exam?

Answer 10

● Caused by smoking, a significant risk factor for cardiovascular disease (e.g. PVD, coronary artery disease, hypertension).

Question 11

What may xanthomata be suggestive of when completing a peripheral vascular exam?

Answer 11

● Raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.

Question 12

What may gangrene be suggestive of when completing a peripheral vascular exam?

Answer 12

● Tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.

Question 13

Describe how you would assess temperature of the upper limb during a peripheral vascular exam?

Answer 13

● Place the dorsal aspect of your hand onto the patient’s upper limbs to assess temperature.

Question 14

What would a normal and abnormal finding be when assessing temperature of the upper limb during a peripheral vascular exam?

Answer 14

● In healthy individuals, the upper limbs should be symmetrically warm, suggesting adequate perfusion.
● A cool and pale limb is indicative of poor arterial perfusion.

Question 15

Describe how you would assess capillary refill time during a peripheral vascular exam?

Answer 15

● Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
● In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
● A CRT that is greater than two seconds suggests poor peripheral perfusion.

Question 16

What should you check with the patient before completing a capillary refill time?

Answer 16

● Prior to assessing CRT, check that the patient does not currently have pain in their fingers.

Question 17

What parameters should be assess surround pulse on the upper limb during a peripheral vascular exam?

Answer 17

● Radial pulse
● Radio-radial delay
● Brachial pulse

Question 18

Describe how you would assess radial pulse in a peripheral vascular exam?

Answer 18

● Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
● Once you have located the radial pulse, assess the rate and rhythm, palpating for at least 5 cardiac cycles.

Question 19

Describe how you would assess radio-radial delay in a peripheral vascular exam?

Answer 19

● Palpate both radial pulses simultaneously.
● In healthy individuals, the pulses should occur at the same time.
● If the radial pulses are out of sync, this would be described as radio-radial delay.

Question 20

What are some causes of radio-radial delay?

Answer 20

● Subclavian artery stenosis (e.g. compression by a cervical rib)
● Aortic dissection

Question 21

Describe how you would assess brachial pulse in a peripheral vascular exam?

Answer 21

● Support the patient’s right forearm with your left hand.
● Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.
● With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.
● Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.

Question 22

Where can the carotid pulse be located?

Answer 22

● The carotid pulse can be located between the larynx and the anterior border of the sternocleidomastoid muscle.

Question 23

Why should you auscultate the carotid pulse before palpating?

Answer 23

● Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit.
● The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.

Question 24

Describe how you would auscultate the carotid artery during a peripheral vascular exam?

Answer 24

● Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.
● Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).

Question 25

Describe how you would palpate the carotid pulse during a peripheral vascular exam?

Answer 25

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 the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.
3. Assess the character (e.g. slow-rising, thready) and volume of the pulse.

Question 26

What should be assess on the abdomen during a peripheral vascular exam?

Answer 26

● Inspection
● Palpation
● Auscultation

Question 27

Describe how you would perform inspection of the abdomen and where you would find the abdominal aortic pulse during a peripheral vascular exam?

Answer 27

● Inspect the abdomen looking for any obvious pulsation. The abdominal aorta can be located in the midline of the epigastrium.

Question 28

Describe how you would palpate the aorta on the abdomen during a peripheral vascular exam?

Answer 28

1. Using both hands perform deep palpation just superior to the umbilicus in the midline.
2. Note the movement of your fingers:

● In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
● If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).

*This is a crude clinical test and further investigations would be required before a diagnosis of an abdominal aortic aneurysm was made.

Question 29

Describe how you would auscultate the renal and aortic arteries during a peripheral vascular exam?

Answer 29

● Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.
● Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.

Question 30

What clinical signs may be observed on the upper limb during a peripheral vascular exam?

Answer 30

● Peripheral cyanosis
● Peripheral pallor
● Ischemic rubour
● Venous ulcers
● Arterial ulcers
● Gangrene
● Missing limbs, toes, or fingers
● Scars
● Hair loss
● Muscle wasting
● Xanthomata
● Paralysis

Question 31

What may peripheral pallor be suggestive of when completing a peripheral vascular exam?

Answer 31

● A dusky-red discolouration of the leg that typically develops when the limb is dependent. Ischaemic rubour occurs due to the loss of capillary tone associated with PVD.

Question 32

What may venous ulcers be suggestive of when completing a peripheral vascular exam?

Answer 32

● 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.

Question 33

What may arterial ulcers be suggestive of when completing a peripheral vascular exam?

Answer 33

● 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).

Question 34

What may hair loss be suggestive of when completing a peripheral vascular exam?

Answer 34

● Associated with PVD due to chronic impairment of tissue perfusion.

Question 35

What may paralysis be suggestive of when completing a peripheral vascular exam?

Answer 35

● Critical limb ischaemia can cause weakness and paralysis of a limb. To perform a quick gross motor assessment, ask the patient to wiggle their toes.

Question 36

Describe how you would assess temperature of the lower limbs during a peripheral vascular exam?

Answer 36

● Place the dorsal aspect of your hand onto the patient’s lower limbs to assess and compare temperature

Question 37

Describe how you would perform capillary refill time on the lower limbs during a peripheral vascular exam?

Answer 37

● Apply five seconds of pressure to the distal phalanx of one of a patient’s toes and then release.
● In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
● A CRT that is greater than two seconds suggests poor peripheral perfusion.
● Prior to assessing CRT, check that the patient does not currently have pain in their toes.

Question 38

What pulses should be checked in the lower limb in a peripheral vascular exam?

Answer 38

● Femoral pulse
● Popliteal pulse
● Posterior tibial pulse
● Dorsalis pedis pulse

Question 39

Describe how you would palpate for the femoral pulse in a peripheral vascular exam?

Answer 39

● The femoral pulse can be palpated at the mid-inguinal point, which is located halfway between the anterior superior iliac spine and the pubic symphysis.
● Check that the pulse is present and assess the pulse volume.

Question 40

Describe how you would assess for radio-femoral delay in a peripheral vascular exam?

Answer 40

● Palpate the femoral pulse and radial pulse simultaneously.
● In healthy individuals, the pulses should occur at the same time.
● If the pulses are out of sync, this indicates radio-femoral delay.

Question 41

What parameters of the femoral pulse should be assessed in a peripheral vascular exam?

Answer 41

● Palpation of femoral pulse
● Assess or radio-femoral delay
● Auscultate to screen for bruits

Question 42

Describe how you would palpate the popliteal pulse in a peripheral vascular exam?

Answer 42

● The popliteal pulse can be palpated in the inferior region of the popliteal fossa.
● With the patient supine, ask them to relax their legs and place your thumbs on the tibial tuberosity.
● Passively flex the patient’s knee to 30º as you curl your fingers into the popliteal fossa. This should allow you to feel the pulse, as you compress the popliteal artery against the tibia.

Question 43

Describe how you would palpate the posterior tibial pulse in a peripheral vascular exam?

Answer 43

● The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
● Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Question 44

Describe how you would palpate the dorsal pedis pulse in a peripheral vascular exam?

Answer 44

● The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones.
● Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Question 45

Describe how you would perform a gross peripheral sensation assessment in a peripheral vascular exam?

Answer 45

1. 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 46

What is Buerger’s test?

Answer 46

● Buerger’s test is used to assess the adequacy of the arterial supply to the leg.

Question 47

Describe how you would perform Buerger’s test during a peripheral vascular exam?

Answer 47

1. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
2. Observe the colour of the limbs.
3. Sit the patient up and ask them to hang their legs down over the side of the bed.

Question 48

When raising the patients legs during Buerger’s test, what would you note about the colour of the limbs?

Answer 48

● 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.

Question 49

When hanging a patients legs down the side of the bed during Buerger’s test, what should you note about the colour of the limbs?

Answer 49

● 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 50

What further assessments and investigations could be performed after a peripheral vascular exam has concluded?

Answer 50

● Blood pressure measurement: to identify significant discrepancies between the two arms suggestive of aortic dissection.
● Cardiovascular examination: to complete assessment of the vascular system.
● Ankle-brachial pressure index (ABPI) measurement: to further assess lower limb perfusion.
● Upper and lower limb neurological examination: if gross neurological deficits were noted during the peripheral vascular examination.