Peripheral vascular examination

In medicine, the peripheral vascular examination is a series of maneuvers to elicit signs of peripheral vascular pathology. It is performed as part of a physical examination, or when a patient presents with leg pain suggestive of a cardiovascular pathology.

The exam includes several parts:

• Position/Lighting/Draping
• Inspection
• Palpation
• Auscultation
• Special maneuvers

Additional recommended knowledge

How to quickly check pipettes?

Weighing the right way

Daily Visual Balance Check

Position/Lighting/Draping

Position - patient should be lying in the supine position and the bed or examination table should be flat. The patient's hands should remain at her sides with her head resting on a pillow.

Lighting - adjusted so that it is ideal.

Draping - the legs should be exposed, the private groin and thigh covered. Drapes are usually placed between the legs.

Inspection

On inspection the physician looks for signs of:

• trauma
• previous surgery (scars)
• muscle wasting/muscle asymmetry
• edema (swelling)
• erythema (redness)
• ulcers - 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.
• hair - hair is absent in peripheral vascular disease (PVD)
• shiny skin - seen in PVD

Palpation

• Temperature - 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 (should be less than 3 seconds)(the time it takes to say capillary return)

Arterial pulses

• Dorsalis pedis artery pulse - on dorsal surface of the foot, running lateral to the tendon of the first toe
• Posterior tibial artery pulse - posterior and inferior to the medial malleolus
• Popliteal artery pulse - behind the knee, typically done with both hands
• Femoral artery pulse - in the femoral triangle / halfway between the ASIS and pubic symphisis

Auscultation

• for femoral artery bruits

Special maneuvers

• Ankle-brachial pressure index (ABPI) assesses peripheral vascular disease
• Venous refill with dependency (should be less than 30 seconds) - the vein should bulge outward with in 30 seconds of elevation for one minute.

• Buerger's Test (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 on 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-Trendelenberg Test (assessment of valvular competence if varicose veins 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 (2cm below and 2cm lateral to the pubic tubercle) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompentence is located below the saphenofemoral junction, and visa versa. This test can be repeated using pressure at any point along the leg until the incompetence has been mapped out.

See also

• Physical examination
• Peripheral vascular disease