Peripheral vascular examination

# Overview
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

# 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-Trendelenburg 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 incompetence 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.

## The Femoral Region
As with examination of any other area of the body, exposure is key. Socks, stockings, pants and skirts should all be removed.
- Begin by simply looking at the area in question, which is on either side of the crease separating the leg from the groin region. Make note of any discrete swellings, which might represent adenopathy or a femoral hernia.
- Palpate the area, feeling carefully for the femoral pulses as well as for inguinal/femoral adenopathy (nodes which surround the femoral artery and vein.... up to one cm in size are considered non-pathologic). If you feel any lymph nodes, note if they are firm or soft, fixed in position or freely mobile (fixed, firm nodes are more worrisome for pathologic states).
- The femoral pulse should be easily identifiable, located along the crease midway between the pubic bone and the anterior iliac crest. Use the tips of your 2nd, 3rd and 4th fingers. If there is a lot of subcutaneous fat, you will need to push firmly.
- A femoral hernia, if present, is located on the anterior thigh, medial to the femoral artery. As it can be transient (i.e. the patient reports its presence yet you find nothing on examination), investigation should include observation as well as palpation while the patient performs a valsalva maneuver, which may make a hernia more prominent.
- Localization of femoral artery
- Palpation of femoral artery

## The Popliteal Region
- Move down to the level of the knee allowing it to remain slightly bent.
- Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). This artery is covered by a lot of tissue and can be difficult to identify, so you may need to push pretty hard. Even then, it may not be palpable, which is not clinically important if you can still identify the more distal pulses.
- Palpation of popliteal artery
- Palpation of popliteal artery

## Below The Knee
Now, turn your attention to the lower leg (i.e. from the knee to the foot). First, examine with your eyes, paying attention to:
- Color: Venous insufficiency is characterized by a dark bluish/purple discoloration. Over time, long standing stasis of blood leads to the deposition of hemosiderin, giving the skin a dark, speckled appearance. If the leg is placed in a dependent position, the bluish/purple discoloration may darken dramatically, further suggestive of venous insufficiency. This occurs as a result of gravity working against an already ineffective blood return system. Patients with severe arterial insufficiency, on the other hand, may have relatively pale skin as a result of under perfusion. When their legs are placed in a dependent position, gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. In cases of severe ischemia, the affected areas (usually involving the most distal aspect of the foot), can appear whitish or mottled, giving the leg a marbleized appearance. Dead tissue turns black (a.k.a. gangrene). Cellulitis (infection in the skin) will cause the skin to appear bright red. These changes can be difficult to detect in people of color.
- Obvious swelling of the leg: If present, is it symmetric? To what level does the swelling exist (i.e. ankle, calf, knee etc.)?
- Nail growth: Nail thickening and deformity often occurs with arterial insufficiency; also with fungal infections.
- Skin: Any obvious growths? Shiny, hairless appearance (seen with arterial insufficiency)? Dilated or varicose superficial veins? Ulceration of the skin can occur in the setting of either venous or arterial disease.
- The bottom of the foot and between the toes: These are common "problem areas," particularly in patients with diabetes who are predisposed as a result of sensory impairment, arterial insufficiency, or both.

## The Distal Pulses
- If there is a lot of edema, you will have to push your way through the fluid-filled tissue to get down to the level of the artery.
- If you are unable to palpate a pulse, find a doppler machine, which should be present on any inpatient floor or ER, and use it to identify the location of the artery. Mark the place with a pen and then go back and again try to feel it with your fingers. In this way, you will be able to determine if the vessel was not palpable on the basis of limited blood flow or if you are simply having a "technical" problem.
- Pulses are rated on a scale ranging from 0 (not palpable) to 2+ (normal). As with edema, this is very subjective and it will take you a while to develop a sense of relative values. In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.

### The Posterior Tibial (PT) Artery
Located just behind the medial malleolous. It can be palpated by scooping the patient's heel in your hand and wrapping your fingers around so that the tips come to rest on the appropriate area. Alternatively, you can reach your fingers over the top of the medial malleolous and approach the artery from this direction. In either case, you are attempting to locate the artery using the tips of your fingers. Pitfalls mentioned with the DP also apply here.
- Localization of posterior tibial artery.
- Forceps grasping posterior tibial artery.
- Examination of posterior tibial artery.
- Doppler USG: Examination of posterior tibial artery.

### The Dorsalis Pedis (DP) Artery
Located just lateral to the extensor tendon of the big toe, which can be identified by asking the patient to flex their toe while you provide resistance to this movement. Gently place the tips of your 2nd, 3rd and 4th fingers adjacent to the tendon and try to feel the pulse. If you can't feel it, try moving your hand either proximally/distally or more laterally and repeat. Common pitfalls include pushing too hard and/or mistaking your own pulse for that of the patient. Palpating the patients radial artery or your own carotid simultaneously with your free hand can help sort this out.
- Location of the dorsalis pedis artery in relation to surrounding structures (surface anatomy)
- Location of the dorsalis pedis artery in relation to surrounding structures (gross anatomy)
- Palpation of the dorsalis pedis artery

# Possible Examination Findings
- Acute Arterial Insufficiency: Note Mottled Appearance of Skin
- Chronic Arterial Insufficiency with Ulcers
- Gangrene of Toes
- Venous insufficiency
- Cellulitis
- Assymetric Leg, Swelling secondary to Deep Venous Thrombosis in Right Leg
- Onychomycosis
- Neuropathic Ulcer in Patient with Diabetic neuropathy
- Venous Stasis Ulcer
- Edema of Right Foot
- Clinical Osteomyelitis: Deep ulcer which permits passage of Q-tip to underlying level of bone
- Massive edema
- Lymphedema