# Chronic Peripheral Arterial Insufficiency
## Upper limb
### Inspection

* cyanosis/pallor
* hair loss
* shiny skin
* ulcerations
* dystrophic nails
* muscle wasting

### Palpation

* measure the blood pressure
* skin temperature (compare bilaterally)
* capillary refill time
* Pulses:
** Abdominal Aorta - palpate for aneurism
** radial, ulnar
** brachial - in antecubital fossa, medial to biceps tendon

### Auscultation

* bruits:
** abdominal aorta
** renal (both anterior and posteriorly)

### Provocative Tests

* Allen's Test for adequacy of circulation to hand
** occlude both the radial and ulnar arteries → patient to make fist
** open hand → release ulnar artery → watch for reperfusion of the palm
*** repeat above for radial artery

### Ankle Brachial Index

* compares the brachial artery systolic BP with the measured systolic BP in the dorsalis pedis and tibialis posterior arteries of the lower limb.
* Requires a manual BP cuff and a vascular doppler probe to perform correctly.
** Locate the brachial pulse in the AC fossa by palpation and with the doppler probe. Determine the systolic pressure in BOTH arms by inflating the cuff until the doppler signal at the brachial artery is obliterated.
** with patient supine, place the center of the bladder posterior and ~ 3 cm above the medial malleolus.
** Locate the tibialis posterior and dorsalis pedis pulses of the leg with the doppler probe. Record the pressure at which the doppler signal is obliterated (highest of DP or TP)
** ABI is the ratio of the highest systolic pressure in the leg being measured to the highest systolic pressure measured in EITHER arm (whichever is higher).
*** ABI > 1.2 implies incompressible tibial arteries (calcification/atherosclerosis, obese lower limb, etc.)
*** ABI 0.9-1.2 is normal
*** ABI 0.8-0.9 suggests mild peripheral arterial disease
*** ABI 0.5-0.8 suggests moderate peripheral arterial disease
*** ABI <0.5 suggests severe peripheral arterial disease

## Lower Limb
### Inspection

* same as UL: cyanosis/pallor, hair loss, shiny skin, ulcerations (especially on the heel), dystrophic nails
** edema (pitting or non)

### Palpation

* skin temperature (compare bilaterally)
* Capillary refill time
* Pulses:
** femoral - midway between the pubis and ASIS
** popliteal - inferior lateral portion of the popliteal fossa (leg slightly flexed)
** posterior tibial - inferior posterior border of medial malleolus
** dorsalis pedis - upper 1/3 of dorsal foot, lateral to EHL
* Radial Femoral Delay
** coarctation of aorta

### Auscultation

* bruits:
** femoral
** popliteal

### Provocative Tests

Buerger’s test
* raise legs to 45° x 1 min → max blanching of skin
* have patient sit with both legs dangling down
** pinkness should return in < 10 s
* look for dusky rubor (reactive hyperemia)
DeWeese’s test
* disappearance of previously palpable distal pulses after walking

## Arterial vs. Venous Insufficiency

| | Arterial Insufficiency | Venous Insufficiency |
| Pain | claudication | in standing position |
| Pulses | ↓ |
| Color | pale, dusky red on dependency |
| Temp | ↓ |
| Edema | | more or less depending from severity of illness mainly if there is a deep venous insufficiency |
| Skin | trophic skin changes, thick nails | brown pigmentation around ankle, stasis dermatitis |
| Ulcers | very painful | painful |