Vascular Examination

Question 1

What are the different stages of this examination?

Answer 1

1. INTRODUCTION
2. GENERAL INSPECTION
3. EXAMINATION HANDS
4. PALPATION PULSES UPPER LIMBS
5. INSPECTION LOWER LIMBS Patient lying flat, limbs fully exposed
6. PALPATION LOWER LIMBS
7. PALPATION PULSES LOWER LIMBS
8. OTHER AREAS
9. CONCLUSION

Question 2

What is covered in the Introduction?

Answer 2

A. Ensure adequate hygiene of hands
B. Introduce self
C. Confirm patient’s name and date of birth
D. Explain the procedure
E. Seek permission to examine
F. Ask if patient is in any discomfort
G. Position patient on examination couch at 45 degrees for UL, and lying flat for LL, limbs fully exposed

Question 3

What is covered in the General Inspection?

Answer 3

A. Look for signs of discomfort or pain

Question 4

What is covered in the examination of hands?

Answer 4

A. Examine hands to assess circulation for colour, warmth and capillary refill time

Question 5

What is covered in the Palpation pulses upper limbs?

Answer 5

A. Palpate both brachial pulses
B. Palpate both radial pulses and then assess rate and rhythm on right radial pulse
C. Palpate both ulnar pulses
D. Perform Allens test on right and left wrists

Question 6

What is covered in the Inspection lower limbs?

Answer 6

Patient lying flat, limbs fully exposed

A. Venous Inspection
shape, discolouration, pigmentation, swelling, varicose veins, scars, oedema,
varicose eczema ulceration
B. Arterial Inspection
colour, hair loss, atrophic shiny skin, ulceration on peripheral pressure points, infection, necrotic and missing toes

Question 7

What is covered in the Palpation lower limbs?

Answer 7

A. Palpate the legs, feeling for temperature of the limb, assessing for tenderness, and checking for pitting oedema
B. Check capillary refill in the foot

Question 8

What is covered in the Palpation pulses lower limbs?

Answer 8

A. Palpate both femoral pulses
B. Palpate both popliteal pulses
C. Palpate both posterior tibial pulses
D. Palpate both dorsalis pedis pulses
E. Use Doppler probe to assess both dorsalis pedis and posterior tibial pulses

Question 9

What is covered in the Other Areas?

Answer 9

A. Measure and record BP

Question 10

What is covered in the Conclusion?

Answer 10

A. Thank patient and wash hands with alcohol gel or water
B. Summarise and present findings orally (and in patient notes)

Question 11

What are the upper limb pulses and where can they be found?

Answer 11

Brachial Artery;
- It is more superficial (and therefore easier to palpate) in the antecubital fossa, where it lies beneath the bicipital aponeurosis. Compress the artery straight down against the medial epicondyle of the humerus.

Radial Artery;
- This artery arises from the brachial artery just below the level of the head of the radius. It is most easily compressed against the distal 1/3 of radius at the wrist, beneath the skin and fascia, lateral to the tendon of flexor carpi radialis.

Ulnar Artery;
- This artery is small and more difficult to palpate. It can be compressed against the ulna at the wrist, just lateral to the tendon of flexor carpi ulnaris and proximal to the pisiform bone.

Question 12

How is capillary refill done?

Answer 12

In adults this is best performed by compressing the pulp of the middle fingers of both hands for 5 seconds before releasing compression and timing how long it takes for the colour (blood) to return. Less than 2 seconds is normal. The digit compressed must be raised to heart level for the assessment to be reliable.

Question 13

What is Allen’s test?

Answer 13

Allen’s Test;
This simple test checks the integrity of the palmar arch arterial anastomosis:
1. First make a tight fist and raise the hand above level of the heart
2. Next, compress both radial and ulnar arteries at the level of the wrist
3. Lower the hand and observe the blanched palm and palmar creases
4. Release the ulnar artery and wait for reperfusion (5-7 seconds is
normal)
5. Repeat from the start, this time checking the radial arterial supply

Question 14

How should the vascular examination be divided up?

Answer 14

Into venous and arterial examination

Question 15

What are varicose veins?

Answer 15

Varicose veins are an example of disease which can affect the venous system.

Question 16

What is a disease which can affect the peripheral arterial system.

Answer 16

Diabetes

Question 17

What is included in the Venous examination?

Answer 17

Venous examination: Inspection and Palpation
* Inspect the limbs looking at/for: shape, discolouration, pigmentation, swelling, scars, (from previous varicose vein surgery and harvesting of veins) oedema, varicose eczema/ulceration (particularly in “gaiter” region) and varicose veins in distribution of long (great) and short (small) saphenous veins
* Palpate for warmth - Run hand up veins feeling for increased warmth
* Look for and palpate any areas of lipodermatosclerosis and oedema
* Palpate any varicosities to assess: Hard/soft, tenderness
* If there appears to be swelling at the level of the calf measure the
circumference of both limbs 10cm below the tibial tuberosity. Deep venous thrombosis (DVT) often causes a tender swelling of the calf.

Question 18

When is the Trendelenburg test done and how?

Answer 18

In the presence of varicose veins know how to perform the Trendelenburg Test for saphenofemoral incompetence.

• With the patient supine, elevate the limb as far as comfortably possible and empty the superficial veins by “milking” the limb.
• Occlude the saphenofemoral junction by pressing 3.5cm below and lateral to the pubic tubercle. Vein lies medial to the artery.
• Ask the patient to stand, maintaining pressure on the saphenofemoral junction.
• Observe the leg, if the varicosities refill immediately there is a leaking perforating vein further down leg. If the pressure controls the engorgement this suggests incompetence at the saphenofemoral junction.
• Release the pressure, if the veins fill rapidly this confirms that the saphenofemoral junction is incompetent.)

Question 19

What is included in the Arterial examination?

Answer 19

Arterial examination: Inspection and Palpation
1. Inspect the limbs carefully, including between toes and on sole of foot, looking at colour (?pale/white), hair loss, atrophic shiny skin, ulceration on peripheral pressure points, infection, necrotic and missing toes
2. Palpate the legs, feeling for temperature of the limb by running back of hand from toes to groin, (both limbs simultaneously to compare warmth).
3. Check capillary refill in the foot.
4. Palpate the pulses in the lower limb:

Question 20

What lower limb pulses should be assessed?

Answer 20

Femoral Artery –The femoral pulse can be palpated below the mid-inguinal point (This is half way along a line drawn between the anterior superior iliac spine and the pubic symphysis in the midline).

Popliteal Artery – With the patient lying flat, flex the knee slightly, and with your thumbs anterior to the knee and your fingers behind, palpate for the pulse with your fingers in the popliteal fossa in the midline, approximately 3cm below the knee crease. Press the artery gently against the tibia.

Posterior Tibial – Palpate posterior to the medial malleolus. (2cm below and 2cm behind medial malleolus)

Dorsalis Pedis – Identify extensor hallucis longus tendon. Using pads of your middle three fingers, palpate gently just lateral to the tendon about one-third of the way down the dorsum of the foot. Press gently down against the tarsal bones. If you press too hard you will obliterate the pulse and if you palpate in the web space there is no bone to gently push against.

Question 21

When is Beurger’s test done?

Answer 21

In the presence of peripheral arterial disease (PAD) know how to perform Beurger’s test.

First assess if any pain or restriction in hips. Stand at foot of bed. Gently elevate legs towards 90 degrees, supporting the heels and keeping legs straight. As blood empties from the legs watch for pallor (and “guttering” of the superficial veins.) In a patient with normal blood vessels the feet will go pale at this angle of 90 degrees. In the presence of diseased vessels pallor will occur before 90 degrees (generally 50 degrees indicates severe ischaemia and 25 degrees indicates critical ischaemia). After a minute ask the patient to sit up and swing legs over side of bed. Observe feet. In presence of peripheral vascular disease the feet will slowly become engorged and purple, changing to a deep red. This occurs due to a reflex vasodilation when oxygenated blood becomes available to oxygen starved tissue. (Reactive hyperaemia.) The time necessary for the “gutters” to fill up is also an indication of severity of arterial insufficiency.)

Question 22

Why and how is the Doppler used?

Answer 22

Quality of pulses:
Healthy blood vessels will produce a triphasic signal when listened to with a Doppler probe. This reflects the flow within the vessel. The first “phase” is accounted for by the antegrade (forward) flow in systole. The second “phase” is due to a retrograde (backwards) flow occurring in early diastole. The final “phase” is antegrade flow in diastole.

In early atherosclerosis or vessels with minimal stenosis this triphasic signal is not able to be produced and so biphasic signal may be obtained. This signal is not always pathological. The biphasic waveform is caused by the loss of the retrograde signal created in early diastole.

In severe vascular disease only a monophasic signal may be heard. This will be weak (quiet) and represented only by antegrade systolic blood flow.

In an acutely ischaemic limb no signal will be found in vessels distal to the site of occlusion.

Posterior Tibial:
- Place small volume of ultrasound gel over the location where posterior tibial pulse was palpated. Using the handheld Doppler probe, place the probe at 45-600 to the skin over pulse and listen to quality of pulse produced.

Dorsalis Pedis:
- As with posterior tibial, place small volume of ultrasound gel over where dorsalis pedis pulse was palpated. Using handheld Doppler probe assess the quality of the pulse.

Question 23

What further investigations would you recommend?

Answer 23

Investigations;
- In peripheral artery disease: Ankle to brachial pressure index

Blood tests;
- Full blood count (FBC) and ESR
- Urea and electrolytes
- Blood glucose
- Serology for connective tissue disease

Microbiology;
- Swab base of any ulcers and culture

Radiology
- Doppler ultrasound

Question 24

When might capillary perfusion be increased or decreased?

Answer 24

Increased perfusion - Increased heart rate and vasoconstriction

Decreased perfusion - Decreased heart rate and vasodilation

Question 25

What are the signs of an ischaemic limb? (6Ps)

Answer 25

Pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis

Poikilothermia, the inability to maintain a constant core temperature independent of ambient temperature, markedly influences both the mental and physical function of affected patients; furthermore, prolonged hypothermia can induce numerous complications.

Question 26

When might Allen’s test be of clinical importance?

Answer 26

The Allen test is a first-line standard test used to assess the arterial blood supply of the hand. This test is performed whenever intravascular access to the radial artery is planned or for selecting patients for radial artery harvesting, such as for coronary artery bypass grafting or for forearm flap elevation.

Question 27

What is an angiogram?

Answer 27

An angiogram is a type of X-ray used to examine blood vessels. Blood vessels don’t show up clearly on ordinary X-rays, so a special dye is injected into the area being examined. The dye highlights the blood vessels as it moves through them. The medical name for this is a catheter angiogram

Question 28

What changes would you find with chronic venous insufficiency?

Answer 28

Chronic venous insufficiency occurs when your leg veins don’t allow blood to flow back up to your heart. Normally, the valves in your veins make sure that blood flows toward your heart. But when these valves don’t work well, blood can also flow backwards.

Question 29

What is meant by the term lipodermatosclerosis (LDS)?

Answer 29

Lipodermatosclerosis is an inflammatory skin condition resulting from underlying venous insufficiency. This is caused by: Incompetent venous valves. Venous outflow obstruction.

Question 30

What symptoms and signs would you find in a leg with chronic arterial insufficiency?

Answer 30

One of the most common causes of arterial insufficiency is atherosclerosis or “hardening of the arteries.” Fatty material (called plaque) builds up on the walls of your arteries. This causes them to become narrow and stiff. As a result, it is hard for blood to flow through your arteries.

Blood flow may be suddenly stopped due to a blood clot. Clots can form on the plaque or, less often travel from another place such as the heart or other artery (also called embolus).

Symptoms depend on where your arteries become narrowed:
- If it affects your heart arteries, you may have chest pain (angina pectoris) or a heart attack.
- If it affects your brain arteries, you may have a transient ischemic attack (TIA) or stroke.
- If it affects the arteries that bring blood to your legs, you may have frequent leg cramping when you walk.
- If it affects the arteries in your belly area, you may have pain after you eat.