A peripheral vascular examination is a medical examination to discover signs of

pathology Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...

in the

peripheral vascular system The peripheral vascular system is the part of the circulatory system that consists of the veins and arteries not in the chest or abdomen (i.e. in the arms, hands, legs and feet). The peripheral arteries supply oxygenated blood to the body, and ...

. It is performed as part of a

physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the pati ...

, or when a patient presents with leg pain suggestive of a cardiovascular pathology. The exam includes several parts: *Position/lighting/draping *Inspection *

Palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...

* Auscultation *Special maneuvers

Position/lighting/draping

Position – patient should be lying in the

supine position The supine position ( or ) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardium, pericardi ...

and the bed or examination table should be flat. The patient's hands should remain at their sides with their head resting on a pillow. Lighting – adjusted so that it is ideal. Draping – the legs should be exposed, the groin and thigh covered. Drapes are usually placed between the legs.

Inspection

On inspection the clinician looks for signs of: *

trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...

* previous surgery (

scar A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a n ...

s) * muscle wasting/muscle asymmetry * edema (swelling) *

erythema Erythema (from the Greek , meaning red) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not asso ...

(redness) *

ulcers An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

– arterial ulcers tend to be on the borders / sides of the foot, neuropathic ulcers on the plantar surface of the foot, venous ulcers tend on be on the medial aspect of the leg superior to the

medial malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...

. * hair – hair is absent in

peripheral vascular disease Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular dise ...

(PVD) * shiny skin – seen in PVD *

Haemosiderin Hemosiderin image of a kidney viewed under a microscope. The brown areas represent hemosiderin Hemosiderin or haemosiderin is an iron-storage complex that is composed of partially digested ferritin and lysosomes. The breakdown of heme gives rise ...

deposits *

Lipodermatosclerosis Lipodermatosclerosis is a skin and connective tissue disease. It is a form of lower extremity panniculitis,Bruce AJ. et al., Lipodermatosclerosis: Review of cases evaluated at Mayo Clinic. J Am Acad Dermatol. 2002. an inflammation of the layer of ...

Palpation

Temperature Temperature is a physical quantity that expresses quantitatively the perceptions of hotness and coldness. Temperature is measurement, measured with a thermometer. Thermometers are calibrated in various Conversion of units of temperature, temp ...

– cool suggest poor circulation, sides should be compared * Pitting edema – should be tested for in dependent locations – dorsum of foot, if present then on the shins. If the patient has been in bed for a longer period of time one should check the sacrum. *

Capillary refill Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. It can be measured by holding a hand higher than heart-level and pressing the soft pad of a f ...

– should be less than 3 seconds.

Arterial pulses

Dorsalis pedis artery In human anatomy, the dorsalis pedis artery (dorsal artery of foot) is a blood vessel of the lower limb. It arises from the anterior tibial artery, and ends at the first intermetatarsal space (as the first dorsal metatarsal artery and the deep pl ...

pulse In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the n ...

– on dorsal surface of the foot, running lateral to the tendon of the first toe *

Posterior tibial artery The posterior tibial artery of the lower limb is an artery that carries blood to the posterior compartment of the leg and plantar surface of the foot. It branches from the popliteal artery via the tibial-fibular trunk. Structure The poster ...

pulse – posterior and inferior to the medial malleolus *

Popliteal artery The popliteal artery is a deeply placed continuation of the femoral artery opening in the distal portion of the adductor magnus muscle. It courses through the popliteal fossa and ends at the lower border of the popliteus muscle, where it branche ...

pulse – behind the knee, typically done with both hands *

Femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the f ...

pulse – in the femoral triangle / halfway between the ASIS and pubic tubercle

Auscultation

* For

femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the f ...

bruit Bruit, also called vascular murmur, is the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery. The bruit may be hear ...

Special maneuvers

* Ankle-brachial pressure index (ABPI) assesses peripheral vascular disease. It may however be unreliable in patients with calcified arteries in the calf (often diabetic patients) or those with extensive

oedema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...

, in which case toe pressure or Toe-brachial pressure index (TBPI) should be measured to aid in the diagnosis. * Venous refill with dependency (should be less than 30 seconds) – the vein should bulge outward within 30 seconds of elevation for one minute. *

Buerger's test Buerger's test is used in an assessment of arterial sufficiency. It is named after Leo Buerger. The ''vascular angle'', which is also called ''Buerger's angle'', is the angle to which the leg has to be raised before it becomes pale, whilst lying d ...

(assessment of arterial sufficiency):
With the patient supine, note the colour of the feet soles. They should be pink. Then elevate both legs to 45 degrees for more than 1 minute. Observe the soles. If there is marked pallor (whiteness), ischemia should be suspected. Next check for rubor of dependency. Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink. If, more slowly, they turn red like a cooked lobster, suspect ischemia. * Brodie-Trendelenburg test (assessment of valvular competence if

varicose veins Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. These veins typically develop in the legs, just under the skin. Varicose veins usually cause few symptoms. However, some indiv ...

are present):
One leg at a time. With the patient supine, empty the superficial veins by 'milking' the leg in the distal to proximal direction. Now press with your thumb over the saphenofemoral junction (2.5 cm below and 2.5 cm lateral to the

pubic tubercle The pubic tubercle is a prominent tubercle on the superior ramus of the pubis bone of the pelvis. Structure The pubic tubercle is a prominent forward-projecting tubercle on the upper border of the medial portion of the superior ramus of the ...

) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompetence is located below the saphenofemoral junction, and vice versa. This test can be repeated using pressure at any point along the leg until the incompetence has been mapped out.

References

External links

* http://jama.ama-assn.org/cgi/content/full/300/2/197 JAMA: Ankle Brachial Index * http://circ.ahajournals.org/cgi/content/full/105/7/886 Circulation: Tools for Coronary Risk Assessment {{Physical exam Vascular surgery Physical examination